OSPITAL NG MAYNILA MEDICAL CENTER DEPARTMENT OF INTERNAL MEDICINE
Name: EROT, ROLANDO Age/Sex: 54/M Address: Pandacan Manila Date of admission: July 28, 2007 Admitting Diagnosis: CVD probably infarction, LMCA in distribution, HCVD, NSR, NIF Residents in charge: Drs. Aguila/Receno/Dimaandal Clerks in charge: Navarro/Ponelas/Reyes
CLINICAL ABSTRACT This is a case, of a 54/M from Pandacan Manila who came in due to changes in sensorium described as increased sleeping time History of Present Illness Patient is a known hypertensive since maintained on with poor compliance. HBP at , UBP at . Patient was apparently well until… Three hours prior to admission, he had sudden onset of left sided body weakness, with slurring of speech. Patient was seen lying on the floor, no vomiting,no ncausea, no seizures, no tremors. Few minutes prior to admission, there was persistence of above conditions and noted increase in sleeping time, hence the admission. Past Medical History No, previous operations, no diabetes mellitus, no hypertension, no bronchial asthma. Family History Patient denies any heredofamilial disease. Personal and Social History Smoker of 20 pack years, occasional alcoholic beverage drinker Review of Systems General: no fever, no weight loss HEENT: no blurring of vision, no tinnitus Respiratory: no cough, no difficulty of breathing Cardiac: no palpitation, no chest pain GIT: No abdominal pain, no diarrhea Urinary: no dysuria, no oliguria Endocrine: no polyphagia, no polyuria, no polydypsia Rheuma: No joint pains Hematology: No easy bruisability Physical Examination: Drowsy to stuporous, wheelchair borne Vital Signs: BP: 150/100 HR: 82 RR: 19 Temp: 36.5C HEENT: Anicteric sclera, pink palpebral conjunctivae, no nasoaural discharge, no cervical lymphadenopathies, (-) distended neck veins CHEST AND LUNGS: symmetrical chest expansion, clear breath sounds, no wheezes HEART: adynamic precordium, PMI at 5th ICS LMCL, normal rate, regular rhythm, no murmur ABDOMEN: flat, NABS, soft, nontender. EXTREMITIES: grossly normal, with full and equal pulses Neurological Examination: Drowsy to stuporous, patient aroused by painful stimuli CNI: NA CNII: Pupils equally reactive to light, 2-3mm CNIII, IV, VI: (+) preferential gaze R CN V: Positive corneal reflex CNVII: (+) shallow L NLF CNVIII: NA CN IX, X: weak gag CN XI: NA CNXII: NA
Assessment: CVD probably infarction, L MCA in distribution, HCVD, NSR, NIF PLAN: Patient was admitted under the service of Drs. Changco, Gardaya, Aguila, Receno, Dimaandal. The patient was maintained on NGT, monitoring of vital signs, and input and output, and was hooked on PNSS 1L to run for 8 hours. And the diagnostic exams requested were Cranioal CT scan, Na/K, CXR PA, UA, HDL, LDL, BUA, BUN, Crea, CBC with platelet count, 12L ECG, Chole, TG, FBS, RBS. And the following medications were prescribed: 1. Citicholine 1g TIV every 12 hours, Nifedipine 5mg cap SL prn for BP >180/100, and Mannitol 100cc TIV every 8 hours. He was maintained on O2 support via nasal cannula at 3-41ppm. Monitoring of the vital signs, neuro vital signs, urine output every hour, and CBG every 6 hours. On the first day of admission, BP was 150/100mmHg, CR 89bpm, RR 20cpm, Temp 37degC. No difficulty of breathing, no chest pain, no cough, no seizure, drowsy. Has preferential gaze to the right, pupils reactive to light, 2-3mm, left is also reactive to left, 3-4mm. weak gag. The upper and lower left extremities 1/5, the right extremities are 5/5. He was temporarily on NPO, and maintained on NGT. He was hooked on PNSS 1L to run for 8 hours. Mannitol drip was continued, 100cc x 8hours TIV. Captopril 25mg tab was added to his medications, 1 tab twice a day per NGT. Monitoring was done hourly.