MacMurray Medical Center
Jacksonville, IL

Patient:Say, Doris R.Hosp. #356782Age/Sex/DOB: 81 yrs. F 06 July 1930

Room: ICU #6

Ordering Provider: Samuel Good, MD

History & Physical

History: This is an 81 year old white female admitted through the ED three days ago after falling at her daughter’s home. Paramedics initiated CPR on their arrival to the daughter’s home. Patient was unresponsive and intubated prior to transport to ED. While in ED, labs, CAT scan, and evaluation by Dr. Perfect supported that pt. had suffered a severe deep intracranial bleed suffering a massive CVA. Dr. Perfect decided against Vlla (rFVlla) after discussing the case with me. Based on recent clinical trial data that suggests that treatment with recombinant factor VIIa (rFVIIa) within 4 hours after the onset of intracerebral hemorrhage limits the growth of the hematoma, reduces mortality, and improves functional outcomes at 90 days, further study of this medication in a broader cohort did not result in improved clinical outcomes and often caused other problems for the patient. Based on the CAT scan, the pt.’s bleeding was due to a ruptured blood vessel and caused by a clot. I concurred with Dr. Perfect on this assessment.Patient was transferred to ICU for further evaluation. Pt. remains unresponsive.

History obtained from daughter: Pt. has a hx of hypertension, hypothyroidism, and GERD. Pt. lives 9 months in Florida where her primary physician and nurse practitioner monitor her health. Pt. has lived independently and was active in her community. She flew unaccompanied and without assistance from Sarasota to O’Hare and was at her daughter’s home visiting. Daughter is unsure if pt. took prescribed medications, but she stated that “she c/o a headache and feeling tired earlier in the evening. I gave her two aspirins, and she went to take a nap. I woke her up for supper, and when she came to the kitchen, I asked her how she felt.” The incident occurred immediately after pt. began to respond to daughter’s query.

Current medications: metoprolol tartrate (Lopressor) 50 mg. BID; lisinopril (Zestril) 10 mg. at bedtime; levothyroxine sodium (Synthroid) 25 mcq. Q AM; omeprazole (Prilosec) 20 mg. Q AM and at bedtime.

Daughter denies pt. has history of sexually transmitted diseases, physical/emotional abuse, substance abuse, or mental illness.

Physical: This is an elderly white woman who is 5’4” and weighs 132 pounds. She is in remarkably good shape with no abnormalities to the eye. Skin color is WNLs, turgor is supple, tan, and warm to touch, nails are manicured, hair distribution is normal for age. Neurological exam reveals both pupils are fixed and unreactive to light; the left pupil is dilated, pt. does not response to verbal or pain stimuli. Musculoskeletal exam reveals good range of motion and tone. Cardiovascular: B/P 128/72(L) 122/70 (R); P: 62, reg. bilateral; + pulses in extremities; heart: NSR. Respiratory: Pt. remains intubated on controlled mechanical ventilation (CMV) with 12 breaths/minute; lungs present with some crackles/rales in left lower lobe. Gastrointestinal: No scars; abnormalities in abdominal contour; bowel sounds minimal to absent; liver WNS. Genitourinary: Pt. has an indwelling catheter draining clear amber urine.

Current Treatment: Continue with CMV, indwelling catheter,

  • Anticonvulsants to control seizures
  • Corticosteroids or diuretics to reduce swelling
  • Painkillers