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Lasala Enedina for PCSO

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					OSPITAL NG MAYNILA MEDICAL CENTER DEPARTMENT OF INTERNAL MEDICINE

Name: Lasala, Enedina Age/Sex: 34/F Address: GSIS Metro Homes Sta. Mesa, Manila Date of Admission: July 2, 2007, 7:45 pm Admitting Diagnosis: CNS Infection, Probably TB Meningitis PTB III r/o Diffuse Toxic Goiter Iron Deficiency Anemia Residents-in-charge: Drs. Dalanon/Gutierrez/Gregorio Clerks-in-charge: Velasco/Velasco/Viar

Hospital #: 1705372 Room #: 427

Clinical Abstract This is a case of a 34 year old female who came in due to headache. History of Present Illness Two weeks prior to admission, the patient had right sided headache of 8/10 in severity, throbbing in character, radiating in the nape area, temporarily relieved by Paracetamol intake. She had no vomiting, no seizure, no loss of consciousness, no fever. No medications or consultations were done. Seven days prior to admission, there was persistence of the above symptoms, associated by undocumented fever. The condition prompted the patient to consult at OMMC – ER where CT scan was done. She was given Diclofenac for the pain. Few hours prior to admission, there was persistence of the above symptoms, which resulted to admission of the patient.

Past Medical History The patient denied any hospitalizations, no DM, HPN, PTB

Family History The patient denies any heredo-familial diseases

Personal/Social History: Non-smoker Non alcoholic beverage drinker

Review of Systems: General: with weight loss of 30% in 2, with loss of appetite HEENT: no tinnitus, no blurring of vision Respiratory: no cough, no cold, no difficulty of breathing Cardiovascular: no chest pain, no PND, no orthopnea GIT: no abdominal pain, no diarrhea, no melena, no hematochezia GUT: no hematuria, no dysuria, no oliguria Endocrine: no polyuria, no polydipsia, no polyphagia, with palpitations, heat intolerance, and tremors Hematologic: no easy bruisability Neurologic: no changes in sensorium, no loss of consciousness, no seizure

Physical Examination: Patient is conscious, coherent, not in cardio-respiratory distress o Vital Signs BP: 110/80 HR: 92 bpm RR: 20 cpm Temp: 37.8 C HEENT: Anicteric sclerae, pink palpebral conjuctiva, no naso-aural discharge, no cervical lymphadenopathies, no exophthalmos, with 8 x 4 cm doughy neck mass that move with deglutition Chest and Lungs: Symmetric chest expansion, no retractions, clear breath sounds th Heart: Adynamic precordium, apex beat 5 LICS MCL, no murmurs Abdomen: flat, NABS, soft, non-tender Extremities: no cyanosis, no edema, full and equal pulses Neurologic: Conscious, coherent, oriented to time, person and place Cranial Nerves: I – can smell II – can read II, III– pupils equally reactive to light and accommodation, 3 – 4 mm III, IV, VI – intact EOM V – (+) bicorneal reflex, intact V1 – V3 VII – no facial asymmetry VIII – intact gross hearing IX, X – good gag XI – can shrug shoulders equally XII – tongue at midline upon protrusion Motor: 5/5 5/5 5/5 5/5 Sensory: 100% 100% 100% 100% DTR: ++ ++ ++ ++

(+) Nuchal rigidity, No Babinski, Kernig’s, Brudzinski

Plan: Maintain patient on NGT Maintain patient on NPO except medications. For Cranial CT Scan with Contrast Continue Medications: 1. Myrin P Forte 1 tablet before breakfast once a day through NGT 2. Vitamin B Complex 1 tab once a day through NGT 3. Dexamethasone 4mg/ampule 1 amp every 6 hours through IV 4. Ceftriaxone 2g/vial every 12 hours through IV 5. Pen G 4 million Units every 4 hours through IV 6. Chloramphenicol 1g/vial every 8 hours through IV 7. Omeprazole 40mg/Vial every 12 hours through IV 8. Sucralfate 1g/tablet 1 tablet once a day per NGT 9. Lactulose 30cc through NGT 10. Mannitol 100cc every 4 hours through IV Continue oxygen support via nasal cannula Put to moderate to high back rest Bedsore precaution: turn the patient side to side every 2 hours NVS/VS every hour, Input and output monitoring


				
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