text:  1. cerebrovascular accident . The patient suffered some mild weakness which was attributed to stenosis of the distal right internal carotid artery . This was determined by head CT   head MRI   head MRA   carotid noninvasive studies   transcranial Dopplers . The possibility of a cardiac origin was evaluated by echocardiogram and Holter monitor . Her echocardiogram curiously showed a normal left ventricular size and systolic function   a patent foramen ovale   with a trace right to left shunt   as determined by bubble study   trace MR was present . Previous echoes have shown MVP at the Ona Hospital . Her Holter showed up to 12 beats of SVT   but was otherwise unremarkable . The patient had a normal B12   negative syphilis serologies and normal thyroid function during this hospitalization . She was anticoagulated with heparin and after several days Coumadin was started . Her exact Coumadin dose is undetermined at this point   however it looks like it will be something around 5 mg a day . Her pro time and PTT have normalized at the time of discharge . She needs to be given 5 mg of Coumadin tonight   5  22  92 . In addition heparin should be started to drip on arrival at 400 units an hour . It is discontinued at the time of transport . The patient has received physical therapy and occupational therapy and her recovery is near complete . During evaluation of her neurologic status   it was determined that for several months prior to admission   the patient has been too unsteady to ambulate . On our exam she is found to have a significant amount of ataxia   especially in the midline and the exact cause of this is unknown . There are multiple possible contributions and this is where her need for careful internal medical evaluation has arisen . At the time we were to embark on this evaluation   the patient &aposs family strongly requested that she be transferred to the Sas General Hospital . What follows is a summary of her medical problems and their possible relationship to her ataxia . Her ataxia is likely due to some cerebellar function   though this is not certain . Moreover her MRI did not show any discrete cerebellar lesions . Our leading theory at this point is that her cerebellar dysfunction relates to perineoplastic syndrome   relating to her history of breast Ca . As I mentioned above   her evaluation was limited by her cardiologic status at the time . While mammogram and CA-15.3 and breast exam are all normal   the idea of a perineoplastic syndrome with or without concomitant breast Ca has reared its head . Two possible markers are anti-Hu syndrome and anti-Yo antibody . These tests were sent on the 18th and are pending at the time of discharge . The results can be obtained by paging me   Do A. Joasscchird   M.D. at 834-364-2251 . I will be happy to furnish the results . The patient has a history of MI in 1989 . Echocardiogram no longer shows wall motion abnormalities . EKG   when the patient goes out of left bundle branch block transiently shows an anterolateral Q  wave inversion . We would like to discontinue her Isordil to improve upon some orthostatic hypotension   but we are not certain whether her heart will tolerate this . Persantine thallium is scheduled at this time   but is yet to be performed . The patient has a history of orthostatic hypotension x many years . It has been evaluated in the past without success . During her hospitalization   we confirmed the presence of this   even when she was hydrated with saline   to a fractional excretion of sodium of 2 . Studies of her autonomic system did not document any dysautonomia . Studies of skin galvanic conduction were normal and her RR interval evaluation was not abnormal . This is a chronic problem but may be contributing to her current weakness and inability to walk . Florinef is to be considered   however stopping the Isordil is one goal . The patient has a history of bronchiectasis from a childhood pneumonia . In addition there is a distant history of M. kansasaii infection . This has been evaluated by Dr. Screen at Sas General Hospital and probably relates to her lung xray . CT at the Ona Hospital in 1989 showed similar findings . A chest CT was to be performed and may be yielding . A PPD was placed and is to be read on Saturday   4 26th . The left volar forearm has the PPD just proximal to the wrist crease and a candida albicans placed just distal to the antecubital fossa . The patient has a history of deep venous thrombosis in 1990   for which she received 6 months of Coumadin . Dopplers of her lower extremities were negative on this admission . It is doubtful that she has chronic PE   but this is one consideration . It is likely that she has pulmonary hypertension from her lung disease   and so this is a consideration . The patient had mild hyponatremia during this hospitalization with a sodium as low as 131 . We think this is likely due to an SIADH as she is euvolemic . This can be evaluated further and is not a problem at this time . The patient has glaucoma . Her medications are as listed below . Her ophthalmologist is aware of transfer . His name is Ettrent Can and he can be reached at 678-233-5033   b 549 . DOCTORS DISCHARGE ORDERS  Propanolol 5 mg. p.o. t.i.d.  hold for SBP less than 110    Isosorbide 5 mg. p.o. t.i.d.   hold for SBP less than 110   Colace 100 mg. p.o. b.i.d. Pilocarpine 4 one drop q.i.d. O.D. Pilocarpine 2 one drop b.i.d. O.S. Betasan 0.5 one drop b.i.d. O.D. . Bacitracin ointment one drop O.D. q.h.s. Ciprofloxacin 500 mg. one p.o. b.i.d. x four more days  until 5  25  92    for recently discovered siderobacter UTI . Coumadin 5 mg. p.o. q.h.s. She needs her dose on 5  22  92 . Heparin i.v. drip at 400 units per hour   on her arrival . In addition the patient requires occupational therapy and physical therapy .