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Nator

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					Ospital ng Maynila Medical Center Department of Internal Medicine

Name: Nator, Reynaldo Age/Sex: 34/M Address: Manila Date of admission: July 4, 2007 Admitting Diagnosis: CVD probably infarct, HCVD, Cardiomegaly, ICRBBB, NSR, Physicians-in-charge: Dr. Changco/Torres/Roxas/Estrada CIC: Villanueva/Villarama/Ybanez

Hospital No.: 1705670 Room #: Infirmary IM 314 Date of Discharge: Final Diagnosis: CVD infarction, right parietal area & basal ganglia, HCVD, cardiomegaly, ICRBBB, NSR, NIF

Clinical Abstract This is a case of a 50 year old male from Sta. Mesa Manila who came in due to left-sided body weakness History of Present Illness Three hours prior to admission the patient was in the bathroom when he experienced sudden onset of left sided body weakness associated with slurring of speech . No headache, no vomiting, no loss of consciousness, no fever. Seek consult at St. Martin de Porres Charity Hospital with an assessment of CVD, HTN bleed vs. infarct Right, HTN uncontrolled he was medicated with 2 doses of clonidine 75 mg sublingual, advised to have Ct scan and admission but due to financial constraint opted to transfer to our institution hence consult and subsequent admission. Past Medical History Denies Hypertension, Diabetes Mellitus, Bronchial Asthma Family History Diabetes Mellitus – mother No Hypertension, no Bronchial Asthma Personal and Social History Smoker Occassional alcoholic beverage drinker Review of Systems General: no loss of appetite, no weight loss, no fever HEENT: no blurring of vision, no headache, no epistaxis, no dysphagia Respiratory: no cough, no colds Gastrointestinal: no abdominal pain, no change in bowel movement Genitourinary: no urinary frequency, no dysuria, no hematuria, no oliguria Endocrine; no polyuria, no polydipsia, no polyphagia Hematologic: no easy bruisability, no bleeding tendency Neurologic: no headache, no vomiting, no loss of consciousness Physical Examination: Upon admission patient was conscious, coherent and not in respiratory distress o Vital Signs: BP 140/90 HR: 88 RR:20 Temp: 37.1 C HEENT: pink palpebral conjunctivae, anicteric sclerae, no tonsillopharyngeal congestion, no cervical lymphadenopathy CHEST AND LUNGS: symmetrical chest expansion, no retractions, clear breath sounds th HEART: adynamic precordium, PMI at 6 ICS LMCL, normal rate, regular rhythm, no murmur ABDOMEN: globular, normoactive bowel sounds, soft, nontender, noted enlarged liver EXTREMITIES: grossly normal extremities, no cyanosis, no edema. Neuro: E4V5M6 Cerebral : oriented in 3 spheres

CN I : N/A CN II: 3 mm EB CN III, IV, VI: intact EOMS, pupils 2-3 mm CN V: intact V1-V3 CN VII: shallow left nasal folds CN VIII: intact good hearing CN IX, X: good gag CN XI: can shrug shoulder R>L CN XII: tongue slightly deviated to the left

MOTOR

SENSORY

DTR

5/5

4/5

100%

100%

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5/5

4/5

100%

100%

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(+) babinski left, no nuchal rigidity, no kernigs, no brudzinksi ASSESSMENT:

COURSE IN THE WARDS: At the Emergency Room, patient was placed in soft diet with strict aspiration precautions. Diagnostics done were cranial CT scan, RBS, BUN, Creatinine, Sodium, Potassium, 12 Lead ECG, CXR-AP, CBC with PC, Urinalysis, FBS, HDL, LDL, Triglyceride, Total Cholesterol, and Blood uric acid. Medications include: 1. Citicholine 1g IV every 8 hours. 2. Captopril 25 mg 1 tab PO as needed for BP >/= 185/110mmHg Patient was advised to have moderate high back rest. Patient was also started with Mannitol 100ml TIV initially then every 4 hours. Oxygen support via nasal cannula was given. On the first hospital day in the emergency room, vital signs were stable. Patient is conscious, coherent, with complaint of headache, no vomiting and GCS=15. CT scan was requested. On the second hospital day, vital signs were stable. Patient has complaint of headache and still had weakness on the left side with motor grade of 0/5 in the left arm and 2/5 in the left lower extremity. Mannitol was discontinued. Patient was started on Tramadol 50 mg PO then every 8 hours. Additional medications include: 1. Aspirin 80 mg PO once a day after lunch 2. Imidapril 10 mg PO once daily On the third hospital day, patient had stable vital signs and no chest pain, no dyspnea, no headache. Mannitol was tapered to every 6 hours. Other medications were continued. On the fourth hospital day, patient still had vital signs and no subjective complaints. Mannitol was again tapered to 100 cc TIV every 8 hours for 3 doses, then every 12 hours for 2 doses, then once a day. Other medications were continued. Patient was continuously monitored. On the fifth hospital day, patient’s vital signs were stable. Simvastatin 40 mg tab OD was started and Maniitol tapering was continued. On the sixth and seventh hospital day, the patient was stable, with no headache, no dyspnea, and no progression of neurologic deficit. Present management was continued.

LABORATORIES Hematology report Normal Values WBC RBC Hgb Hct MCV MCH MCHC Platelets Neutrophils Lymphocytes Monocytes Eosinophils Basophils Blood chemistry BUN Creatinine Sodium Potassium Cholesterol HDL LDL Glucose Uric Acid Normal Values 2.50-7.10 53-115 140-148 3.6-5.2 5.20-6.20 1.00-1.60 1.10-3.80 3.90-6.10 0.11-0.43 July 5, 2007 3.49 72 145 3.8 6.2 1.1 4.09 6.49 0.33 4.8-10.8 x 109 /L 4.0-6.20 x 1012 /L 12-16g/dl 37-47 % 80-90 fL 27-31 32-36 150-400 x 10^9/L 55-57 20-30% 0-7% 0-3% 0-1%

July 2007 9.2 5.7 16.4 48.3 84.5 28.7 34 189 72.5 16.6 4.4 1.5 0

04,

Urinalysis Color Transparency Epithelial Cells Mucus Threads Amorphus Urates Pus Cells Erythrocytes Cast Albumin Sugar Sp gravity pH bacteria Yeast cells 7/8/07 Yellow Slightly turbid Few Few Moderate 1-3 4-7 Neg Neg 1.020 6.5


				
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