INOVA MOUNT VERNON HOSPITAL
250! Parker’s Lane, Alexandria, VA 22306
ADMISSION HISTORY AND PHYSICAL
PATIENT NAME: LINDSLEY, WINSTON J
HISTORY #: 01063261
ATTENDING MD: Roger V Gisolfi, MD
ADMITTED: 06/03/2002
ROOM: 5A 51402
HISTORY OF PRESENT ILLNESS: This 51-year-old man is admitted to Mount Vernon
Hospital for the third time during one continuous hospital stay. His history is as follows:
The patient was admitted to Fairfax Hospital on April 30, 2002 with chest and back pain.
Computerized tomography scan showed a thoracic aortic aneurysm, type , for which he
underwent emergency repair. Concurrently, he was noted to have right hemiplegia and a
Computerized tomography scan of the brain showed a left middle cerebra] artery territory
infarct. Carotid Doppler showed dissection of the left carotid artery as well as right
carotid plaque. Echocardiogram showed no cardioembolic source, The postoperative
course was complicated by K pneumonia. Computerized tomography of the chest showed
left pleural effusion which was drained for two liters of fluid on May 22, 2002. The
patient was also discovered to have bilateral calf deep venous thromboses for which he
was treated with Lovenox 30 mg subcutaneously q. I 2h. The patient was admitted to
Mount Vernon rehabilitation on May 23, 2002, the day after his thoracentesis. Carotid
Dopplers were repeated on May 24, 2002 and it was found that the calf deep venous
thromboses had either migrated or extended to the level of the thighs. Contact was made
with the cardiovascular surgical service at Fairfax and it was felt that a this time the
patient was safe for therapeutic levels of anticoagulation. Accordingly, on May 24, 2002,
the patient was admitted to Mount Vernon Hospital for the second time in two days, this
time to the medical service, for heparin infusion and three days of bedrest for deep
venous thrombosis. This having been accomplished, followup chest x-ray shows reaccumulation of bilateral pleural effusions.
The patient underwent thoracentesis by ulmonary medicine consultant, Richard Hoffman,
MD. The right chest was tapped for 800 cc on May 28, 2002. The left chest was tapped
for 1800 cc on May 29, 2002. Also, on May 29, 2002, the patient experienced a syncopal
episode while working with physical therapy. Even though the patient was a medical
admission at this time, he had been maintained as a medical hoarder on the rehabilitation
unit for continuity of care. However, following his syncopal episode lie was moved up to
the intermediate care unit for 24-hours on a monitored bed. During this time, there was
no evidence of ectopy and cardiac enzymes remained flat. The patient was then returned
to medical boarder status on the rehabilitation unit. Following thoracentesis, intravenous
heparin was changed to a therapeutic level of Lovenox and Coumadin anticoagulation
was begun. Tonight, June 3, 2002, after discussion with Trigone Insurance, the patient is
being discharged from the medical service and readmitted to the rehabilitation service
without change in his hospital bed.
MEDICATIONS: The patient’s medications at the time of readmission to rehabilitation
consist of Catapres patch TTS-3 weekly, Norvasc 10 mg q.a.m., Prevacid 30 mg q.a.m.,
Lasix 40 mg q.a.m.,
INOVA MOUNT VERNON HOSPITAL
2501 Parker’s Lane, Alexandria, VA 22306
DISCHARGE SUMMARY
PATIENT NAME: LINDSLEY, WINSTON J
HISTORY #: 0
Page 2 of2
The patient’s medications at the time of rehabilitation discharge consisted of Catapres
TTS-3 patch, Norvasc 10 mg q.am., Prevacid 30 mg qam., Lasix 40mg q.a.m., potassium
chloride 20 mEq qam., abetalol 400 mg q8h. and heparin infusion per deep venous
thrombosis protocol.
Roger V Gisolfi, MD
005/24/2002 4;43P;T05/28/2002 I0:48A;875-- 1010146,000110146,It4Sl
CC: Roger V Gisolfi, MD
INOVA MOUNT VERNON HOSPITAL
2501 Parker’s Lane, Alexandria, VA 22306
DISCHARGE SUMMARY
PATIENT NAME: LINDSLEY, WINSTON J
HISTORY #: 01063261
ATTEND MD; Roger V Gisolfi, MD
ADMITTED: 05/23/2002
DISCHARGED: 05/24/2002
LIST OF DIAGNOSES:
Cerebrovascular accident - Left middle cerebral artery territory infarct.
2. Right hemiparesis.
3. Global aphasia.
4. Apraxia.
5. Dissection of left internal carotid artery.
6, Thoracic aortic aneurysm, type 1, status post repair April 30, 2002.
7. Klebsie!la pneumonia.
8. Bilateral pleural effusions.
9. Dysphagia.
10. Bilateral lower extremity deep venous thrombosis.
NARRATIVE SUMMARY: This SI-year-old man was admitted to Fairfax Hospital on
April 30, 2002 with chest and back pain. Computerized tomography scan showed a
thoracic aortic aneurysm, type 1, and the patient underwent an emergency repair. The
patient was concurrently noted to be right hemiplegic. Computerized tomography scan of
the brain showed a left middle cerebral territory infarct. Carotid Doppler study showed a
dissection of the left carotid artery as well as right carotid plaque. Echocardiogram
showed no cardioembolic source. The patient’s postoperative course was complicated by
Klebs pneumonia. Computerized tomography scan of the chest showed a loculated left
pleural effusion; this was drained of two liters of fluid on May 22, 2002. The patient was
also found to have bilateral calf deep venous thromboses which was medicated with
Lovenox 30 mg subcutaneously q.12h. On May 23, 2002, the patient was admitted to
Mount Vernon rehabilitation.
PHYSICAL EXAMINATION: The physical examination at the time of admission to
Mount Vernon rehabilitation showed a nonverbal, alert gentleman and history was
therefore unobtainable from the patient. He had a right hemiparesis with a strength of
grade 3/5. He was expressively and receptively aphasic. He was also noted to be apraxic.
A nasogastric tube was in place for feeding purposes.
HOSPITAL COURSE: On the morning following admission, foilowup bilateral lower
extremity venous Dopplers were obtained and showed that the calf deep venous
thrombosis had migrated into the thigh. Contact was made with the cardiovascular
surgical service at Fairfax Hospital and I was advised that the patient was safe for
therapeutic levels of anticoagulation. Accordingly, the patient was begun on intravenous
heparin drip and placed at bedrest. He is, accordingly, on May 24, 2002 discharged from
the rehabilitation service and admitted to the internal medicine service of Dr. Gisolfi.
INOVA MOUNT VERNON HOSPITAL
2501 Parker’s Lane, Alexandria, VA 22306
ADMISSION HISTORY AND PHYSICAL
PAT NAME: LINDSLEY, WINSTON
HISTORY #: 01063261
Page 2 of 2
potassium chloride 20 mEq q.a.m., Peri-Colace one capsule h.s., Colace IO mg bid.,
Ambien 10 mg h.s., labetalol 500 mg q.8h., Lovenox 100 mg q.12h. subcutaneously,
Coumadin 6 mg qp.m., Lactulose p.rn. constipation, Dulcolax suppository prn.
constipation, Fleets enema p.rn. constipation and Catapres 0.1 mg p.o. g.óh. p.r.n. for
systolic blood pressure greater than 150 or diastolic blood pressure greater than 90.
ALLERGIES: The patient has no known drug allergies.
PAST MEDICAL HISTORY: The patient is a known hypertensive.
PHYSICAL EXAMINATION: Physical examination at the time of readmission to
rehabilitation shows an alert, globally aphasic gentleman. He has a right hemiparesis but
has antigravity strength. His pulmonary status is stable at this time. Pulse oximetiy is
93% on room air.
Roger V Gisolfi, MD
D 06103/2002 6: P; T 06/05/2002 2:52 P; 875-- 1025344 000125344, #456373
CC: Roger V Gisolfi, M
INOVA MOUNT VERNON HOSPITAL
2501 PARKERS LANE, ALEXANDRIA, VA 22306
(703)664-7171
RADIOLOGY REPORT
PATIENT NAME: LINDSLEY, WINSTON MED REC #: 1063261
D. 0.8.: 05/31/1950
REQUEST if: 90015
ORD. DR.: HOFFMAN, RICHARD DATE OF EXAM: 06/11/2002 03:O9PM
ATN. DR.: GISOLFI, ROGER
NS/BED: 5A 514 MS 14-02
Page I oil
EXAMINATION: -CHEST2 VIEWS
REASON FOR EXAM: CONGESTION FOLLOW UP PLEURAL EFFUSION
INTERPRETA TION:
DATE: 06/11/02.
PROCEDURE: CHEST.
INDICATION: 52 year old male with chest congestion.
TECHNIQUE: Two views.
FINDINGS: Since 06/03/02, the left pleural effusion has decreased, but there is now an
area of atelectasis at the left base.
The exam is otherwise unchanged. Again, the heart is large, the soda ectatic, and there is
evidence of previous sternotorny. The right lung remains clear. Surgical clips overlie the
right upper chest.
IMPRESSION: IMPROVED LEFT PLEURAL EFFUSION WITH NEW LEFT
BASILAR ATELECTASIS. OTHERWISE NO CHANGE SINCE 06/03/02.
READING OR: CALVIN NEITHAMER
ELECTRON/CALL V SIGNED BY: CALVIN NEITHAMER MD
HMG - 06/12/2002 06:4 7
INOVA MOUWT VERNON HOSP(TAL
2501 PARKERS LANE, ALEXANDRIA, VA 22305
(703)664-7171
RADIOLOGY REPORT
PATIENT NAME: LINDSLEY, WINSTON MED REC #: 1063261
D.O.B.: 05/31/1950
REQUEST #: 90014
ORD. DR.: GISOLFI, ROGER
DATE OF EXAM: 06/03/2002 O8:39AM
ATN. DR.: GISOLFI, ROGER
NS/BED: 5A 574 M5
Page 1 of I
EXAMINATION: -CHEST 2 VIEWS REASON FOR EXAM: SOB
INTERPRETATION:
EXAM: CHEST.
HISTORY: Shortness of breath.
FINDINGS: Two films were obtained. The head is enlarged. There is a reaction present
at the lung bases particul8rly on the left consistent with a left pleural effusion. Surgical
clips are seen over the right upper thorax. Sternotomy sutures are present.
Compared with the study of 05/31 there has been some improvement in the previously
described vascular congestive changes.
READING DA: JOHN DE GRAZIA
ELECTRONICALLY SIGNED By: JOHN Off GRAZIA MD
HMG - 06/03/2002 16:58