Inpatient Consultation
Patient Case Number: IPC81- Helton, Linda
Patient Name: Linda Helton | DOB: 10-11-63 | Sex: F
Date of Service: 08-15-XX | Physician: Felix Goode, MD

# Reason for Consultation: Sudden onset of weakness

# History of Present Illness:

This is a 55 y/o female patient has a history of dialysis and apparently presented to ABC Hospital on 08-15-XX with a sudden onset of weakness. Her history of includes ESRD secondary to membranoproliferative glomerulonephritis. She has also has a history of seizures and hypertension. She has had an AV graft placed.

Workup including imaging studies show evidence of a CVA with a right hemiparesis. Initial head CT scan was negative. MRI shows evidence of advanced atrophy with ischemic changes as well as two acute ischemic infarcts in the left thalamus.

# Medical History: ESRD on HD, membranoproliferative glomerulonephritis, seizures, htn

# Past Surgical History: AV fistula

# Social History: Reportedly, she is married. She was ambulatory occasionally with use of an assisted device prior to this admission.

# Physical Examination: Clinical examination reveals an alert female, arousable, was presently being dialyzed. She has some decreased sensation on the right with a definite weakness noted in the right upper and right lower extremity, 4/5 strength in the upper extremities on the right and 4-to 3+/5 strength in the right lower extremity, 4+/5 strength is noted on the left. Reflexes are blunted. There is decreased response to pain on the right. No significant neglect was noted. Her hand dominant is unknown as well.

# Diagnoses:

1. CVA with right hemiparesis.

2. ESRD on HD

3. Membranoproliferative glomerulonephritis

4. Seizures, continue on Depakote

5. Htn-continue on Lisinopril and Metoprolol

# Plan:

At this point in time, PT, OT and speech therapy have been initiated. We will monitor her progress, consideration for inpatient rehab will be strongly given in this matter.

# Electronically Signed By: Felix Goode, MD

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