IGTANLOC_ Epirose - 24h - DOC by dredwardmark



Name: IGTANLOC, Epirose Age/Sex: 64/F Address: 844 D. Castillas, Sampaloc, Manila Date of Admission: June 2, 2007 Admitting Diagnosis: Space-occupying Lesion prob. intracranial mass Residents-in-charge: Drs. Magbiray/Gonzales/Estrada Clerks-in-charge: Smith/Sope/Sy 24 Hour History

Hospital #: 1693441 Room #: 314

This is a case of a 64-year-old female who came in due to weakness and numbness on the right side of the body. History of Present Illness Four days prior to admission, patient experienced weakness on the right side of the body. Patient also felt numbness on the right side described as stiffening felt from the toe upwards felt every 3-5 minutes followed by generalized body stiffening, upward rolling of the eyes, and loss of consciousness. Speech was also noted to be slurred. There was no vomiting, no seizures or tremors, no fever, no headache, and noted unusual sensations prior to episode. No consult was done and no medications were taken. Two days prior to admission, the same symptoms recurred then resolved spontaneously without consult done or medications taken. One day prior to admission, the same symptoms were noted and also observed to resolve spontaneously. No consult done, and no medications taken. Few hours prior to admission, the patient was asymptomatic but still opted to seek consult at the OMMC emergency room. The patient then had sudden stiffness of the extremities with flexion and extension, and with upward rolling of the eyes, and loss of consciousness. Patient noted to have felt numbness as well. Diazepam was administered and the patient was admitted. Past Medical History Patient claims to have no history of hypertension, diabetes mellitus, asthma, heart disease, kidney disease. Patient has not undergone any surgical procedures in the past. Family History Patient has family history of asthma on the maternal side. Personal/Social History Patient is not a smoker, and not an alcoholic beverage drinker. Review of Systems Constitutional: no fever, no anorexia, no weight loss, no chills, no night sweats HEENT: no headache, no dizziness, no blurring of vision, no ear pain, no ear discharge, no nasal congestion, no nasal discharge, no sore throat, no dysphagia, no hoarseness Respiratory: no cough, no difficulty of breathing Cardiovascular: no chest pain, no orthopnea, no PND, no palpitations Gastrointestinal: no abdominal pain, no constipation, no diarrhea, no melena, no hematochezia Genitourinary: no dysuria, no discharge, no hematuria Musculoskeletal: no muscle/joint pain, no limitation of movement Endocrine: no polyphagia, no polydipsia, no polyuria Physical Exam Patient is conscious, coherent, and not in cardiorespiratory distress Vital signs HR 64

RR 20

Temp 37.1 C

BP 100/70

HEENT, neck: Pink Palpebral conjunctiva, anicteric sclera, no nasoaural discharge, no tragal tenderness, no nasal septum deviation, no tonsillopharyngeal inflammation, no cervical lymphadenopathy, no palpable mass Chest/Lungs: symmetric chest expansion, no retractions, clear breath sounds th Heart: adynamic precordium, PMI at 5 ICS LMCL, S1S2 distinct, no murmurs Abdomen: flat, normoactive bowel sounds, no bruit, soft, no mass, no tenderness on palpation Extremities: no cyanosis, no jaundice, no clubbing of fingers, pulses full and equal Neuro: Patient is awake, coherent, and responsive to her surroundings. Patient is oriented to time, place, and person Cranial nerve exam I – intact II, III – pupils equally reactive to light 2-3 mm III, IV, VI – intact EOM function V – corneal reflexes present both eyes VII – shallow nasolabial fold on the right VIII – intact hearing IX,X – intact gag reflex XI – can shrug shoulders equally XII – tongue deviated to the right Sensory Motor

Assessment: Space-occupying lesion, probably intracranial mass Plan: For cranial CT Scan, BUN, Creatinine, and electrolytes measurement, and for admission. Course in the wards: On the first hospital day, the patient was admitted into the infirmary ward with stable vital signs. Patient was hooked to plain NSS x 12 hours. Fluid input and output were monitored and patient was put on regular diet with special aspiration precautions. Cranial CT Scan, ECG, and chest Xray were requested and performed, as well as laboratory tests – urinalysis, electrolytes, LDL, HDL, cholesterol, triglycerides, BUN, Crea, CBC with Platelet count. CT Scan results stated presence of age-related cortical and cerebellar atrophy and atherosclerotic internal carotid arteries. ECG showed sinus tachycardia. Patient was watched for active seizures, changes in sensorium, and hypoglycemia with CBG measurements every 6 hours. Vital signs and neuro vital signs were monitored every hour. Medications given were Phenytoin 100 mg cap TID, Diazepam 1amp TIV for active seizures, and Vitamin B complex OD.
Laboratories Complete Blood Count Normal Values WBC 4.8-10.8 x 109 /L RBC 4.0-6.20 x 1012 /L Hgb 12-16g/dl Hct 37-47 % MCV 80-90 fL MCH 27-31 MCHC 32-36 Platelet 150-400 x 10^9/L Neutrophils 55-57 Lymphocytes 20-30% Monocytes 0-7% Eosinophils 0-3% Basophils 0-1% Blood Chemistry Normal Values 13.8 BUN 4.4 12.9 40 91.7 29.6 32.3 535 59.9 32.7 6.3 0.9 0.2 Creatinine Sodium Potassium Chloride 2.5 - 7.10 mmol/L 53 – 115 umol/L 140-148 mmol/L 3.6 – 5.2 100-108 mmol/L

June 2, 2007 3.31 42 142 4.5 106

To top