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					OSPITAL NG MAYNILA MEDICAL CENTER DEPARTMENT OF INTERNAL MEDICINE

Name: De Guzman, Elena Age/Sex: 85/F Address: 1345 A INT 5-A Linao St. Apacible Paco, Manila Date of admission: April 29, 2008 Admitting Diagnosis: CVD probably infarct RMCH in distribution HCVD, LVH, NSR Residents in charge: Dr. Filio/Gregorio/Sarmiento Clerk-in-Charge: Fabian/Item/Junsay

Hospital #: 1829351

PATIENT DISCHARGE SUMMARY This is a case of a 85 year-old female who was admitted due to left-sided weakness. History of Present Illness Patient is a known case of heart disease on Losartan 50mg/tab and Enalapril 10mg/tab. Patient was apparently well until.. 5 hours PTA, patient is having her breakfast when the relative noted her falling on her left side. There was no loss of consciousness, no vomiting, no headache, no seizure, no chest pain, no fever hence brought to PGH where she was advised to transfer to other hospital due to lack of vacancy and consulted on our institution hence admission Past Medical History No DM No allergy to food/drugs No B, no history of PTB (?) Family History (-) HPN (-) DM (-) cancer (-) asthma Personal and Social History Non-Smoker Non-alcoholic beverage drinker Review of Systems has weight loss of 5% in 12 months Physical Examination: Awake, slurred speech Vital Signs: BP: 140/90 HR: 80 RR: 21 Temp: 37.5 °C HEENT: pink palpebral conjunctivae, anicteric sclerae, no NAD, no mass, no lymphadenopathies, no neck vein engorgement CHEST AND LUNGS: symmetrical chest expansion, no retractions, clear breath sounds, no crackles, no wheezing HEART: adynamic precordium, normal regular rate rhythm, PMI 5th LICS MCL, no murmur ABDOMEN: flat, normoactive bowel sound, soft, non tender, no mass EXTREMITIES: grossly normal, no cyanosis, no edema, full and equal pulses Neurological Examination: Patient is awake, slurred speech CN I – not assessed CN II – PERTL 2-3 mm (+) ROR CN III, IV, VI – intact EOM on both eyes CN V – (+) bicorneal reflex CN VII – no facial asymmetry CN VIII – respond to sound CN IX, X – weak gag reflex CN XI – shrug shoulder R>L CN XII – tongue deviated to left

5/5 5/5

1/5 1/5 ++ ++

5/5 5/5
(+) Primitive reflex – Babinski (left)

1/5 1/5

++

++

Assessment: CVD probably infarct RMCH in distribution HCVD, LVH, NSR Plan: for Admission Laboratories: Chest X-ray Na, K,Cl CT scan U/A Sputum AFB x 3 days CBC with PC BUN, Crea 12L ECG ABG

Medications: 1. 2. 3.

Citicoline 1gm TIV q12 if not available citicoline 100mg/mL 2mL TID Captopril 25mg/tab 1 tab TID Simvastatin 2mg/tab 1 tab OD at HS

Moderate high back rest VS q1 NVS q1 Hook to O2 support via nasal cannula at 2-3 lmp Course in the Wards:

LABORATORY RESULTS: HEMATOLOGY: DATE WBC RBC HgB Hct MCV MCH MCHC RDW-CV Platelets Neutrophils Lymphocytes Monocytes Eosinophils Basophils Pro/Mye/Jv Stabs Blasts ESR mm/hr Ret NORMAL 4-11 x 109 /L 4-6 x 1012/L 13.5-18 g/dL 0.37 – 0.54 % 80-100 fL 27-31 pg 320-360 g/L 11-15% 15-45 x 1012 /L 0.5 – 0.7 0.2 -0.44 0.02-0.09 0.02-0.04 0 – 0.02 0.00 0.02 – 0.04 0.00 0-10 / 20 0.005- 0.015 4/27/08 4.4 2.46 6.5 0.20% 80.1 26.4 330 13.2 347 4/28/08 3.6 1.96 5.1 15.2% 77.6 26.2 33.7 12.5 331 78.1 8.2 11.0 2.7 0.0 4/29/08 7.7 2.77 7.5 21.8 78.6 27.1 34.5 13.1 374 90.3 4.6 4.7 0.2 0.0

NRBC Malaria LE BT CT CRT RBC Morph URINALYSIS DATE Color Transparency Sp. Gravity pH Sugar Albumin RBC WBC Cast Crystals Epithelial cells Bacteria Mucous Thr Pus cells Amorphous urates Uric acid

1 – 3 min 6 – 15 min 50% / hr

NORMAL

4-26-08
YELLOW

TURBID 1.016 – 1.022 4.6 – 6.5 (-) (-) 0-2 /hpf 0-5 / hpf Acidic/alkali Few (-) Few

MANY/HPF

MANY 15-20/HPF FEW 15-20/HPF MODERATE

BLOOD CHEMISTRY DATE Glucose BUN mmol/L Crea umol/L BUN:Crea Total Protein Albumin Globulin Ca mmol/L Mg mmol/L Na mmol/L K mmol/L Cl mmol/L Phosphorus Cholesterol HDL mmol/L LDL mmol/L Triglycerides TB umol/L DB umol/L IB umol/L AlkPho umol/L SGPT SGOT Urate mmol/L Amylase CPK total CPK –MM CPK – MB Troponin T/I ABG

NORMAL 4.10 – 6.10 2.5 – 6.4 53 – 115 64 – 83 g/L 38 – 51 g/L 23 – 35 g/L 2.2 – 2.6 0.74 – 1.0 140 – 146 3.6 – 5.2 100 – 108 0.81 – 1.58 5.2 – 6.2 0.91 – 1.56 1.1 – 3.8 0.34 – 2.28 0.00 – 17.1 0.55 – 7.45 3.42 – 13.7 36 – 92 0 .0 – 0.3 U/L 0.0 – 34 U/L 0.13 – 0.44 1 – 63 U/L 21 – 232 U/L 8 – 97 U/L

4-09-08 3.93

72 29

184

4-26-08 Ph pCO2 pO2 HCO3 TCO2 Bels O2st 7.471 27.40 106 20.20 21.00 1.4 98.5

FECALYSIS= NEGATIVE/ NO OVA/ NO PARASITE CT-SCAN RESULT There is a probable subacute infarct in the left thalamus on top of malacic with some peripheral gliotic change and white matter hyalenosis and or degeneration as above described. Most probable vascular calcification in the left corona radiate. Mild to moderate cerebrocerebellar atrophy and wallerian degeneration Old lacunar infarcts, right lentiform nucleus.


				
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