History of Present Illness: This was the first hospital admission for this 72-year-old female who was admitted through the emergency department with a history of tingling along the right side of her body with slurred speech not associated with recent headache or trauma. Interestingly she stated that she had noted a fluttering sensation in her chest several times over the past month or so. Her medical record revealed an overnight hospitalization approximately 12 years ago for atrial fibrillation. No follow up information was documented.

Exam at the time of admission revealed a well-developed elderly white female who was alert and cooperative with a mildly depressed affect. She gave a fair history that was augmented by her daughter and granddaughter. Blood pressure initially was 185/100. Positive findings included carotid bruits and venous stasis changes of the lower extremities. Heart was irregularly irregular, no fib or flutter detected at that time. Initial neurologic assessment revealed a right facial droop with weakness and clumsiness of the right hand and leg. Sensory exam was intact. No visual field cut was noted. Repeat exam later the same day revealed continued right facial droop and thick speech, with residual but somewhat improved right-sided weakness.

 
Lab and X-Ray Data: EKG revealed NSR with nonspecific STT wave changes. CT scan of the head demonstrated cortical atrophy only. CBC: Hgb 14.1, Hct 40.9, WBC 7400, platelets 252,000. Random blood sugar 118. BUN 12, creatinine 1, sodium 138, potassium 4.2, chloride 105, CO2 25.5, cholesterol 185, HDL 42, triglycerides 125. TSH 1.95, PT and PTT on admission were normal. INR on the day of discharge was 1.7. A barium swallow demonstrated normal swallowing function with no intrinsic abnormality of the esophagus or swallowing mechanism.

 
Hospital Course: The patient was admitted and placed on heparin. After discussion with Neurology it was elected to treat her with at least 3 months of anticoagulation with warfarin given the probability of recurrent TIA/stroke in the face of her apparent ongoing problem with atrial fibrillation. With this regimen the patient stabilized. She had approximately 50% improvement in her speech and complete resolution of her right hemiparesis and no hemisensory loss. She was seen by physical therapy, occupational therapy, and speech therapy. Barium swallow was done because of her complaint of a lump in her throat and some questionable swallowing dysfunction. A carotid ultrasound demonstrated moderate bilateral disease of both ICA’s with approximately 35% stenosis. Her heparin was discontinued once she had reached therapeutic PT and PTT times. The Social Services department was consulted and provided education and counseling to the patient and her family.

The patient was discharged to her daughter’s home on the 4th hospital day in improved and stable condition. Home services have been arranged for physical, occupational, and speech therapy. Ultimately she desires to return to her own home once she has completed rehabilitation and can function independently. Medications are as on admission with the addition of warfarin 5 mg qd. Follow up appointment is with me in the office in 10 days. Pro time will be drawn on Monday. The patient and her family have been provided with a complete set of written discharge instructions.