+

Admissions Conference

Clerk Shari Atanacio

+General Data R.M. 63 Male Right handed Married Roman Catholic Filipino Mechanic Tondo, Manila DOA: March 12, 2010

+ Chief Complaint

Left sided weakness

+History of Present Illness• January 25, 2010 (11PM) – sudden loss of consciousness after urination– head hitting the banister– spontaneously regained consciousness after 30 seconds– event unrecalled by the patient– no headache, vomiting, blurring of vision, diplopia– no weakness, numbness – Ospital ng Maynila after 30 mins • cranial xray: no fractures• BP 160/100• PE was essentially unremarkable• A> Hypertension• Losartan 50mg/tab OD and Hydrochlorothiazide 12.5mg/tab OD• Discharged improved and stable

+History of Present Illness

January 25 - Feb 2nd week2010

apparently well able to do daily activities no complaints of headache, vomiting, weakness, numbness

+History of Present Illness

Feb 3rd week 2010

2 episodes of headache throbbing, frontotemporal area, graded 5/10, occurring

spontaneously, relieved by intake of Paracetamol

+History of Present Illness

Feb 4th week – March 4, 2010

Apparently well Asymptomatic

+History of Present Illness• March 5, 2010 (4pm)– sudden lapses in remote and recent memory– unable to recall events, dates– able to recognize faces, remember the names of the people

and things, and knows where he placed his things– answered to inquiries appropriately

– L sided weakness • difficulty in ambulating and gripping objects • BP was at 130-140/90 • self-medicated with ASA for 3 days

– Change in behavior• Easily irritable

+ Review of Systems• (-) weight gain (-) weight loss • (-) rashes, easy bruising• (-) cough, dyspnea• (-) ear discharge (-) hemoptysis, (-) night sweats• (-) constipation, (-) diarrhea, nausea, vomiting• (-) heat intolerance, palpitations• (-) cyanosis, cold intolerance• (-) dysuria, (-) flank pain• (-) polyphagia (-) polydipsia, (-) polyuria, (-) joint pains

+ Past Medical History

(+) Right forearm fracture (1980s) (+) HPN – (January 25, 2010) maintained on Losartan

50mg/tab OD and HCTZ 12.5mg/tab OD; UBP: 130-140/90 HBP: 150/90

(-) DM, stroke

+ Family Medical History

(+) HPN - mother (-) DM, Thyroid disorder, stroke

+ Personal and Social History

12 smoking pack years Alcoholic beverage drinker from 1972-75 with

consumption of 3 beers/day for 3 years Denies illicit drug use Mixed diet

+ Physical Examination on Admission• Conscious, coherent, not in cardiorespiratory distress • BP: 130/80 PR 76 bpm, regular RR 18 cpm T 36.5C BMI

26.5• Warm moist skin, no active dermatoses • Pale palpebral conjunctivae, Anicteric Sclerae • Moist buccal mucosa, no nasoaural discharge,

epistaxis, tonsil not enlarged, non-hyperemic posterior pharyngeal wall

• Supple neck, no cervical lymph adenopathies, thyroid not enlarged, (-) carotid bruit

+ Physical Examination on Admission Symmetrical Chest Expansion, no retractions, clear

breath sounds Adynamic Precordium, AB 5h LICS MCL, no murmurs Flabby abdomen, normoactive bowel sounds, soft, non

tender, no masses Pulses full and equal, no edema, no cyanosis

+Neurological Exam Conscious, coherent, oriented to person, disoriented to time/date

and place, cannot remember events but can recognize faces, remembers names of people and things, L hemineglect, follows command

MMSE: 16/30• Pupils 3-4 mm OU, equally reactive to light, (+) Visual threat OU,

(+) direct and consensual light reflex, no ptosis• Funduscopy: (+) ROR, indistinct disc margins• EOM full and equal• V1V2V3 intact, can clench teeth• No facial asymmetry, can raise both eyebrows, can close eyes

tightly• Gross hearing intact, no lateralization on Weber, AC>BC AU

+Neurological Exam • Uvula midline on phonation• Can raise both shoulders against resistance• Tongue midline on protrusion• No muscle atrophy, fasciculations, spasticity, rigidity• MMT 5/5 on RUE,RLE 4/5 LUE/LLE • (-) Dysmetria and dysdiadokinesia• DTR’s ++• (-) Babinski• No sensory deficits• No nuchal rigidity, Brudzinski, Kernig’s sign

+ Is there a neurologic deficit?

Focal neurologic deficit Meningeal signs Increased intracranial pressure

+ Is there a neurologic problem?

• Focal Neurologic Deficit– Disturbance in intellectual function• memory• Emotions/behavior• language• seizure

– Cranial nerve deficits– Weakness or paralysis of extremities– Incoordination, poor equilibrium– Reflex asymmetry, pathological reflexes– Sensory impairment

+Where is the neurologic problem?

Levelize Cerebrum

Disturbed higher intellectual functions Behavioral changes Hemiparesis

+Where is the neurologic problem? Localize

Frontal lobe – hemiparesis Temporal lobe – behavior and memory changes Parietal lobe – constructional apraxia, hemineglect

+Where is the neurologic problem? Lateralize

Right Cerebrum (Frontal, Temporal and Parietal lobe)

+What is the neurologic problem?• congenital/developmental

• trauma

• Infection

 

• degenerative

• neoplasm

• vascular

 

• metabolic/Endocrine

• Intoxication

• Nutritional deficiency

• demyelinating

• immunologic

+ Assessment

Intracranial Hemorrhage, probably Chronic Subdural Hematoma, R cerebrum

+ Plans

• CBC with plt• PT, aPTT• Serum Na, K, crea, BUN• FBS, lipid profile• UA• Cranial MRI• CXR• 12L-ECG 

Mannitol 20% 75cc/IV q6 Lactulose 30cc ODHS, hold

if BM >3x/day For evacuation of

hematoma

Diagnostics Therapeutic