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DISCHARGE SUMMARY Joondalup Health Campus Cnr Grand Blvd & Shenton Ave JOONDALUP WA 6027 Tel: (08) 9400 9400 | Fax: (08) 9400 9054 JHC MRN: MN00665257 NAME: FRANCIS SUTHERLAND ADDRESS: 785 PATERSON ROAD PICKERING BROOK WA 6076 Ph 08 9293 8387 GP NAME: DANIEL STRINGER U 20 STIRK MEDICAL GROUP, 20/35 SANDERSON RD, LESMURDIE, WA 6076 ADMISSION NO: AN11245768 Date of Birth: 27/07/1943 (73 years) Date Admitted: 04/10/2016 Date Discharged: Consultant: Steven Jujnovich Summary Status: Version 0.3 - Draft Completed By: De La Hunty, Daisy (RMO) on 07/10/2016 PRINCIPAL DIAGNOSIS (AT DISCHARGE) Principal Diagnosis; PICA stroke Lateral medullary stroke ADDITIONAL DIAGNOSES (COMORBIDITIES) Urinary retention IDC inserted 2x failed TOV Constipation Managed with aperients PR bleeding Small amount on a single occasion, likely secondary to haemorrhoids + recent constipation Nil further bleeding PAST HISTORY Previous Medical History; Hypertension Hypertensive cardiomyopathy (EF 25%) Mitral regurgitation + tricuspid regurgitation Pulmonary hypertension CCF CKD Cognitive impairment Domestic Situation; Lives at home with wife in a rental property. Independent with ADLs. 4 children. Receives full aged pension from Centrelink. INVESTIGATIONS ===Bloods=== CUMULATIVE ELECTROLYTES (Serum) Na K Cl HCO3 Urea Creat mmol/L mmol/L mmol/L mmol/L mmol/L umol/L (134 - 146)(3.4 - 5.5)(95 - 108)(22 - 32)(3.0 - 8.0)(40 - 120) Date Time Lab.No. 02/09/16 18:11 142 4.5 111 21 9.1 134 88415657 03/09/16 07:14 141 4.7 108 24 8.8 117 88415807 06/09/16 07:15 141 4.0 103 30 11.2 147 88486271 07/09/16 07:45 139 4.4 102 30 12.2 152 88486296 12/09/16 11:00 138 4.4 103 29 11.7 129 88436103 18/09/16 08:40 140 4.9 103 28 14.2 148 88504355 19/09/16 08:50 138 4.5 102 31 14.6 158 82370813 22/09/16 08:20 141 4.6 104 29 11.4 135 82375558 28/09/16 07:45 144 4.5 107 29 12.9 141 82375073 FRANCIS SUTHERLAND 27/07/1943 MN00665257 AN11245768 COMPLETED BY De La Hunty, Daisy on 07/10/2016 PRINTED BY De La Hunty, Daisy on 07/10/2016 Joondalup Hospital Pty Ltd ABN 61 106 723 193 trading as Joondalup Health Campus Page 1 of 4 06/10/16 07:40 142 4.7 107 29 14.0 138 82283906 THROMBOPHILIA SUMMARY REPORT Lab Number: 84489960 VTE Risk ATIII . . . . . . : 101 % (75 - 125) NO Protein C . . . . : 108 % (70 - 140) NO Protein S . . . . : 95 % (70 - 150) NO aPCR . . . . . . : 1.1 NO FVL Mutation . . : Not Detected NO PT Gene Mutation . : DETECTED HETEROZYGOUS 3x Lupus A/C . . . . : POSITIVE 9x * Homocyst.(Random ) : 17.8 umol/L (3.7 - 13.9) HI ?? ACL Ab . . . . . : Positive ACL IgM . . . . . : 23 MPL U/mL LOW POS ACL IgG . . . . . : 3 GPL U/mL NEG LIPIDS (Serum) Chol Trig HDL-C LDL-C Ratio mmol/L mmol/L mmol/L mmol/L (See) Date (< 5.5) (< 2.0) (> 0.9) (< 3.4) (Below) Lab. No. 03/09/16 Fasting 6.2 0.7 1.6 4.3 3.9 88415807 04/09/16 Fasting 5.8 1.4 1.3 3.9 4.5 88495803 FBP normal TFTs normal Fasting BSL normal B12/folate normal Iron studies normal Infectious Status; N/A RADIOLOGY CT CAROTID ANGIOGRAM (5/09/2016) AMENDED REPORT Original Report reported by DR Steven Irons CT NECK AND CEREBRAL ANGIOGRAM - FRANCIS SUTHERLAND CLINICAL DATA Increased BP - cardiomyopathy - dissection? TECHNIQUE Arterial phase imaging from aortic arch to vertex. FINDINGS No significant stenosis nor aneurysm detected over the circle of Willis. No significant stenosis to the arterial vessels of the neck. No significant stenosis to the vessels arising of the arch of aorta. No mass intracranially nor oedema. No soft tissue mass within the neck or upper thorax. No sinister bone lesion. Multifocal endplate facet arthropathy expected for age is noted. CONCLUSION No arterial dissection detected over the neck and head region. This study does not exclude recent ischaemic stroke. Amended Report After review by the PRC radiology group, addendum is issued. The arterial phase examination demonstrates attenuated flow in the left vertebral artery beginning around the level of the C2 then becoming occluded at the C1 base of skull articulation level remaining occluded until a small amount of flow is demonstrated in the distal left vertebral artery likely retrograde flow. This is likely from dissection/thrombosis. On-call report supplied by Dr M. Bartlett, I-TeleRAD Radiologist: O. C. Report .......................................................................................................................... CAROTID DOPPLER (5/09/2016) BILATERAL CAROTID DOPPLER ULTRASOUND FRANCIS SUTHERLAND 27/07/1943 MN00665257 AN11245768 COMPLETED BY De La Hunty, Daisy on 07/10/2016 PRINTED BY De La Hunty, Daisy on 07/10/2016 Joondalup Hospital Pty Ltd ABN 61 106 723 193 trading as Joondalup Health Campus Page 2 of 4 Clinical Details: Exclude carotid stenosis. Right Side: Hypoechoic mixed plaque is seen at the right carotid bulb. This results in a .......................................................................................................................... MRI HEAD (5/09/2016) MRI BRAIN .......................................................................................................................... CT HEAD (12/09/2016) CT BRAIN - FRANCIS SUTHERLAND CLINICAL DATA Known CVA diagnosed on 05-09 (MRI). Large left cerebellar infarct. Occluded left vertebral artery. ? New stroke. TECHNIQUE Comparison is made to the CT angiogram dated 02-09-2016. FINDINGS Established infarction involving inferomedial left cerebellar hemisphere indicative of infarction in the distribution of left posteroinferior cerebellar artery. No signs of recent cortical infarction or haemorrhage. No extra-axial collection. CONCLUSION Confirmed infarction (established) involving the left inferomedial cerebellar hemisphere. This infarct is slightly heterogeneous in echotexture but there is no gross haemorrhagic transformation. No other signs of recent deep nor cortical infarction although this diagnosis could not be entirely excluded on the basis of CT within the first 24- 48 hours. On-call report supplied by Dr C. O'Donnell, I-TeleRAD Radiologist: O. C. Report .......................................................................................................................... MRI HEAD BED NOTES (13/09/2016) MRI BRAIN Clinical Details: Recent left cerebellar infarct. Sudden headache and increasing dizziness and ataxia. ?Re-infarct haemorrhagic transformation or other. Findings: The recent left PICA cerebellar hemispheric infarct has matured, with reduction in the degree of mass effect when compared to the presentation study of 5 September 2016. A new area of left lateral medullary infarction has developed in the lateral medulla. This measures 7 mm, and is characterised by restricted diffusion. This component was not present on the prior study. There is a second very small acute infarct in the dorsal left cervicomedullary junction, 2 mm. The prior posterior fossa mass effect has resolved. There is mild T1 hyperintensity in the subacute cerebellar infarct, consistent with diapedesis. No focal haemorrhage. There are persistent moderate periventricular small vessel ischaemic changes in the parietal lobes with a band of transverse gliosis through the inferior splenium. MRA shows occlusion of the intracranial left vertebral artery which reforms in a small stump adjacent to the basilar artery, similar to the prior MRA. No flow is seen in the left PICA on either study. Comment: A new left lateral medullary infarct has developed since 5 September 2016. There is minor diapedesis into the PICA infarct, the mass effect resolved. Persistent thrombus distal left vertebral artery. Radiologist: Dr S. Davis PROGRESS & MANAGEMENT Progress & Management; 73 year old male admitted for rehabilitation following a left cerebellar stroke. Initially presented with sudden onset of dizziness, nausea and vomiting. Stroke confirmed on imaging (MRI). Conservatively managed (clopidogrel and statin commenced). Recurrent episode of headache, dizziness and increased ataxia during admission. Repeat MRI revealed new left lateral medullary stroke. In light of thrombophilia screen showing patient was highly pro-thrombotic (results below), warfarin was commenced in place of clopidogrel to decrease risk of future stroke. Persistent associated neurological deficits included nystagmus on left lateral gaze, diplopia, ataxia and imbalance (sitting and mobilising), and left upper limb heaviness and parasthesiae. Some improvement in symptoms over the course of admission, however ongoing rehabilitation required. Ongoing neuropathic left facial/eye pain after previous stroke and redness (likely conjunctivitis). Referred for ophthalmology review at SCGH and pregabalin commenced. FRANCIS SUTHERLAND 27/07/1943 MN00665257 AN11245768 COMPLETED BY De La Hunty, Daisy on 07/10/2016 PRINTED BY De La Hunty, Daisy on 07/10/2016 Joondalup Hospital Pty Ltd ABN 61 106 723 193 trading as Joondalup Health Campus Page 3 of 4 ALLERGIES NKDA ALLIED HEALTH ADVICE Allied Health - Social Work; Family meeting with wife, sister, son and daughter-in-law. Discussed current deficits compared to baseline function and plan for ongoing rehabilitation. Allied Health - Physiotherapy; Receptive to physiotherapy and deemed a good candidate for rehabilitation. Ongoing issues with sitting and standing balance (leaning to left) and gait (ataxic, wide-based). Education and training regarding using assistance for transfers/mobilisation. Allied Health - Occupational Therapy; Functional review and cognitive assessment. Education and training in ADLs, mobility and goal setting. Allied Health - Speech Therapy; Swallow assessment completed: nil dysphagia after initial presentation. However subsequent asssesment following second CVA revealed dysphagia. Allied Health - Dietetics; Education regarding nutritional optimisation and reduction of stroke risk via dietary changes. FUTURE MANAGEMENT PLAN Transfer to Midland Hospital for ongoing rehabilitation with thanks. PARTICIPANTS Steven JUJNOVICH Attending Doctor - Geriatric Medicine Steven JUJNOVICH Admitting Doctor - Geriatric Medicine DANIEL STRINGER GP U 20 STIRK MEDICAL GROUP, 20/35 SANDERSON RD, LESMURDIE, WA 6076 p: 08 9291 4599 f: 08 9291 4566 FRANCIS SUTHERLAND 27/07/1943 MN00665257 AN11245768 COMPLETED BY De La Hunty, Daisy on 07/10/2016 PRINTED BY De La Hunty, Daisy on 07/10/2016 Joondalup Hospital Pty Ltd ABN 61 106 723 193 trading as Joondalup Health Campus Page 4 of 4 on or other. Findings: The recent left PICA cerebellar hemispheric infarct has matured, with reduction in the degree of mass effect when compared to the presentation study of 5 September 2016. A new area of left lateral medullary infarction has developed in the lateral medulla. This measures 7 mm, and is characterised by restricted diffusion. This component was not present on the prior study. There is a second very small acute infarct in the dorsal left cervicomedullary junction, 2 mm. The prior posterior fossa mass effect has resolved. There is mild T1 hyperintensity in the subacute cerebellar infarct, consistent with diapedesis. No focal haemorrhage. There are persistent moderate periventricular small vessel ischaemic changes in the parietal lobes with a band of transverse gliosis through t