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发表于 2012-6-11 10:22:06
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再发一篇 consultation note
Mr XX is a pleasant 80 year old married right handed gentleman admitten to HSN May 29th having sustained a left hemospheric stroke. the vascular surgical service was consulted with respect to this neurologic event in the context of recurrent severe left carotid stenosis.
past health is remarkable for previous left carotid endarterectomy years ago in Toronto, previious aortic reconstruction for apparent aneurismal disease, coronary artery disease, possible cardiac arrhythmia and pacemaker insertion.
Medications ordinarily include Warfarin amongst a number of others. Mr. XX is not currently smoking.
As stated above, this gentleman underwent remote coratid endarterectomy years ago in toronto, the right internal carotid artery is reportedly chronically occluded. On May 29th, this gentleman experienced right upper extremity weakness, associated with expressive aphasia, this occerred while taking Warfarin, He was admitted to the edical Service at HSN. his right lower extremity strength has improved. his speech has improved somewhat although he still exhibits some hesitation of speech. Carotid duples ultrasound reportedly suggests recurrent severe left carotid stenosis and again, chronic right internal carotid artery occlusion.
I was asked by Dr.XX to review this gentleman in the context of his recurrent symptomatic severe left carotid stenosis. I attended Mr.XX once I was out of the OR. This gentleman was accompanied by his stepson.
Onexamination, Mr.XX exhibits some mild expressive aphasia and hesitancy of speech, I cannot elicit any real gross focal neurologic deficits otherwise today. He appears reasonably robust for his advanced age.
IMPRESSIOM:
I share concern Mr. XX sustained a left hemispheric neurologic event secondaryy to reported recurrent severe left carotid stenosis despite Warfarin anti-coagulation. I review the issues in detail. Ordinarily we would pursue further imaging with a view to potential re-do left carotid endarterectomy to diminish his future risk for recurrent stroke . thsi gentleman's creatinine is elevted in the 175 range and this would need to be taken into consideration in the context of CT angiography. I have offered referral to one of our nephrologists with a view ti CT nagiography and subsequent re-do left carotid endarterectomy if high grade recurrent stenosis is confirmed.
Mr. XX would like to consider this option before making any final decisions, He is somewhat undecided. He is going to discuss the issues and options with his family menbers. I will follow-up with Mr.XX in the next 24 to 48 hours. We will take things from there. I will keep you informed on how things proceed. |
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