Neurology Case Studies

DISCHARGE SUMMARY

ADMITTING DIAGNOSES

1. Closed head trauma, with persistent nausea and vertigo.

2. Preexisting homonymous hemianopsia.

FINAL DIAGNOSES

1. Status post closed head trauma (concussion), with spontaneous resolution of nausea and vertigo.

2. Cervical sprain.

3. Homonymous hemianopsia from postoperative stroke 1 month prior to admission.

HISTORY

A 67-year-old white man who was admitted following an automobile accident.  His car was apparently struck in the right front fender region by another car.  He apparently lost consciousness immediately upon the impact, and did not regain consciousness until the emergency medical technicians had already arrived, a time he currently estimates at 15 minutes.  He believes that he struck his forehead against his windshield, and probably against the rearview mirror as well, although not with great force.

Recent medical history is significant for hydrocele repair.  A few days following surgery, he developed homonymous hemianopsia.  Since then, he has been placed on aspirin.

PREADMISSION MEDICATIONS

Aspirin 1 t.i.d.  Stool softener 1 daily.

PHYSICAL EXAMINATION

Currently, approximately 16 hours following admission, lying in bed with soft cervical collar, in no apparent discomfort.  He has remained afebrile through his overnight stay, with stable vital signs.  Blood pressure has been approximately 160/90 this afternoon.  HEENT:  Tiny laceration over the right forehead, with mild swelling.  No palpable deformities.  Cardiovascular:  Regular rate and rhythm without murmur or gallop.  Carotids 2/2 without bruit.  No edema.  Toenails generally appear a bit clubbed, fingernails do not.  No cyanosis.  Neurologic:  Right visual field homonymous hemianopsia, which the patient reports is unchanged from prior to the accident.  Cranial nerves 2-12 otherwise intact.  Deep tendon reflexes 2+ at knees.  Toes downgoing.  Strength 5/5 throughout all extremities.   Coordination intact.  No Romberg sign.  Sensation grossly intact to light touch.

Cervical spine x-rays reportedly showed no fracture.  Head CT scan showed evidence of previous ischemic infarct in the optic region, but no new lesions nor acute bleeding.

Was admitted by the emergency room physician, and observed overnight, with frequent neurologic checks.  His nausea resolved by the morning following admission, and by the afternoon he was able to walk around without problem.

Is now being discharged, to continue use of cervical collar, usual aspirin, and stool softener.  He also has some oral pain medication on hand from his recent surgery, and he is to take this as needed.

CONDITION ON DISCHARGE

Good.

FOOTNOTE

Line 9 to end (Page 1).  The dictator said hemianopsia throughout; hemianopia is preferred in Dorland’s, hemianopsia in Stedman’s.

Line 23 (Page 1).  A comma, not the semicolon suggested by the physician, is the correct punctuation.

Line 35 (Page 1).  Exam was expanded to Examination in the heading.

Line 43 (Page 1).  Nor was changed to or to correct grammar.