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					OSPITAL NG MAYNILA MEDICAL CENTER DEPARTMENT OF INTERNAL MEDICINE

Name: LIBREA, Reynaldo Address: 1558 San Diego St., Sampaloc Manila Date of Admission: 28 January 2008 Admitting Diagnosis: CVD hemorrhage, basal ganglia right and occipital area right HCVD, LVH, ST, NIF s/p CVD with left residual Residents-in-charge: Drs. Filio/Indon/Areja Clerks in charge: Drs. Corpuz/Cruz/Cutchon 24 HOUR HISTORY This is a case of 68 year old male from Sampaloc who came in due to left sided body weakness.

Hospital #: 1793671 Age/Sex: 68/F

History of Present Illness Patient is a diagnosed case of HCVD s/p CVD last December 2007 in Parañaque General Hospital was sent home with the following medications: Trimetacidine, Metoprolol, and Vitamin B Complex with good compliance. Patient had left sided body deficit but he was able to hold a spoon using left hand. Three days PTA, there was vomiting (1 bout, not quantified), no associated abdominal pain, no fever, no cough, no colds. No chest pain, no headache. No medications taken, no consultation sought. One day PTA, there was still vomiting of 1 bout now associated with weakness of left hand with inability to hold a spoon and associated with drowsiness. No seizures or loss of consciousness. Persistence prompted consult hence admission Past Medical History Denies DM, CAD, BA, CA, HPN No allergies to food or drugs No previous operations or hospitalization Family History (+) DM and HPN – siblings Personal and Social History Non-smoker and nonalcoholic beverage drinker Review of Systems General: no weight loss, no fever, no cough, no colds HEENT: no epistaxis, no tinnitus, no dysphagia Cardiac: no chest pain, no PND, no orthopnea, no easy fatiguability, no palpitation Gastrointestinal: no abdominal pain, no changes in bowel habits. Genitourinary: no dysuria, no oliguria, no hematuria, no polyuria Hematology: no easy bruisability, no bleeding tendencies Endocrinology: no polyuria, no polyphagia, no polydipsia, no heat/cold intolerance Musculoskeletal: no arthralgia, no myalgia Neurological: no seizures, no loss of consciousness Physical Examination: General: drowsy, coherent, in espiratory distress Vital Signs: BP: 240/30 mmHg HR: 89 bpm RR: 21cpm Temp: 36.9°C SKIN: no pallor, no cyanosis, good skin turgor HEENT: anicteric sclerae, pink palpebral conjunctivae, no nasoaural discharge, no TPC, no CLAD, no distended neck veins CHEST and LUNGS: symmetrical chest expansion, no lagging, no retractions, (+) crackles right base HEART: adynamic precordium, PMI at 6th ICS NRRR, no murmur ABDOMEN: flat, normoactive bowel sounds, soft, non-tender EXTREMITIES: grossly normal, full and equal pulses, no cyanosis, no edema NEURO: drowsy, oriented to person CN I – n/a CN II – 2 -3 STRL OU CN III, IV, VI – no preferential gaze. (+) doll’s gaze CN V – (+) bicorneal reflex CN VII – shallow nasolabial fold on the L CN VIII – intact gross hearing CN IX, X – weak gag CN XI – n/a CN XII – n/a motor sensory (+) Babinski, left (-) Brudzinski (-) clonus

Assessment: CVD hemorrhage, basal ganglia right and occipital area right HCVD, LVH, ST, NIF s/p CVD with left residual Plan: For admission

Course in the Wards: Patient was admitted at room 426 under the service of Dr Filio/Indon/Areja. Patient was inserted with NGT and oral feeding at 2100kcal/day in 3 divided meals and 2 snacks. Diagnostics requested were CBG, BUN, crea, Na, K, Cl, cranial CT scan, ECG, CXR-AP, CBC with PC, UA, TG, chole, HDL, LDL, BUA, FBS. Therapeutics given: Mannitol 200 cc TIV now then 100cc TIV q4h, Citicholine 500mg TIV q12h, Hydralazine drip (4 amp Hydralazine in 500cc D5 water) x 20μgtts/min to titrate at 5μgtts/min q30min until BP is ≤≤160/100, and Omeprazole 20mg/cap 2 capsule OD/NGT. Indwelling foley catheter was inserted and connected to urine bag. Patient was hooked to oxygen inhalation via nasal cannula at 2 – 3 LPM. On the first hospital day, patient was referred to Neuro service consultant. Dexamethasone 5mg TIV QID x 3 days was started. Oral feeding was continued. Patient was placed on moderate to high back rest. Vital signs and neuron vital signs were monitored with CBG monitoring every 8 hours

OSPITAL NG MAYNILA MEDICAL CENTER DEPARTMENT OF INTERNAL MEDICINE

Name: LIBREA, Reynaldo Address: 1558 San Diego St., Sampaloc Manila Date of Admission: 28 January 2008 Admitting Diagnosis: CVD hemorrhage, basal ganglia right and occipital area right HCVD, LVH, ST, NIF s/p CVD with left residual Residents-in-charge: Drs. Filio/Indon/Areja Clerks in charge: Drs. Corpuz/Cruz/Cutchon PATIENT’S DISCHARGE SUMMARY This is a case of 68 year old male from Sampaloc who came in due to left sided body weakness.

Hospital #: 1793671 Age/Sex: 68/F

History of Present Illness Patient is a diagnosed case of HCVD s/p CVD last December 2007 in Parañaque General Hospital was sent home with the following medications: Trimetacidine, Metoprolol, and Vitamin B Complex with good compliance. Patient had left sided body deficit but he was able to hold a spoon using left hand. Three days PTA, there was vomiting (1 bout, not quantified), no associated abdominal pain, no fever, no cough, no colds. No chest pain, no headache. No medications taken, no consultation sought. One day PTA, there was still vomiting of 1 bout now associated with weakness of left hand with inability to hold a spoon and associated with drowsiness. No seizures or loss of consciousness. Persistence prompted consult hence admission Past Medical History Denies DM, CAD, BA, CA, HPN No allergies to food or drugs No previous operations or hospitalization Family History (+) DM and HPN – siblings Personal and Social History Non-smoker and nonalcoholic beverage drinker Review of Systems General: no weight loss, no fever, no cough, no colds HEENT: no epistaxis, no tinnitus, no dysphagia Cardiac: no chest pain, no PND, no orthopnea, no easy fatiguability, no palpitation Gastrointestinal: no abdominal pain, no changes in bowel habits. Genitourinary: no dysuria, no oliguria, no hematuria, no polyuria Hematology: no easy bruisability, no bleeding tendencies Endocrinology: no polyuria, no polyphagia, no polydipsia, no heat/cold intolerance Musculoskeletal: no arthralgia, no myalgia Neurological: no seizures, no loss of consciousness Physical Examination: General: drowsy, coherent, in espiratory distress Vital Signs: BP: 240/30 mmHg HR: 89 bpm RR: 21cpm Temp: 36.9°C SKIN: no pallor, no cyanosis, good skin turgor HEENT: anicteric sclerae, pink palpebral conjunctivae, no nasoaural discharge, no TPC, no CLAD, no distended neck veins CHEST and LUNGS: symmetrical chest expansion, no lagging, no retractions, (+) crackles right base HEART: adynamic precordium, PMI at 6th ICS NRRR, no murmur ABDOMEN: flat, normoactive bowel sounds, soft, non-tender EXTREMITIES: grossly normal, full and equal pulses, no cyanosis, no edema NEURO: drowsy, oriented to person CN I – n/a CN II – 2 -3 STRL OU CN III, IV, VI – no preferential gaze. (+) doll’s gaze CN V – (+) bicorneal reflex CN VII – shallow nasolabial fold on the L CN VIII – intact gross hearing CN IX, X – weak gag CN XI – n/a CN XII – n/a motor sensory (+) Babinski, left (-) Brudzinski (-) clonus

Assessment: CVD hemorrhage, basal ganglia right and occipital area right HCVD, LVH, ST, NIF s/p CVD with left residual Plan: For admission

Course in the Wards: Patient was admitted at room 426 under the service of Dr Filio/Indon/Areja. Patient was inserted with NGT and oral feeding at 2100kcal/day in 3 divided meals and 2 snacks. Diagnostics requested were CBG, BUN, crea, Na, K, Cl, cranial CT scan, ECG, CXR-AP, CBC with PC, UA, TG, chole, HDL, LDL, BUA, FBS. Therapeutics given: Mannitol 200 cc TIV now then 100cc TIV q4h, Citicholine 500mg TIV q12h, Hydralazine drip (4 amp Hydralazine in 500cc D5 water) x 20μgtts/min to titrate at 5μgtts/min q30min until BP is ≤≤160/100, and Omeprazole 20mg/cap 2 capsule OD/NGT. Indwelling foley catheter was inserted and connected to urine bag. Patient was hooked to oxygen inhalation via nasal cannula at 2 – 3 LPM. On the first hospital day, patient was referred to Neuro service consultant. Dexamethasone 5mg TIV QID x 3 days was started. Oral feeding was continued. Patient was placed on moderate to high back rest. Vital signs and neuron vital signs were monitored with CBG monitoring every 8 hours On the 2nd hospital day,the patient was maintained on NGT and Oral feeding was continued. Metoclopramide 10mg TIV q8 was given . Hydralazine drip was decreased to 10 μgtts/min then titrate 5 μgtts /min to maintain BP≥160/100. Simvastatin was shifted to 80mg/tab OD at bedtime.Other meds were continued. Vital signs and neuron vital signs were monitored with CBG monitoring every 8 hours. On the 3rd hospital day, the patient was maintained on NGT and Oral feeding was continued. Hydralazine was increased to 55 μgtts/min and titrate to 5 μgtts/min q30min to maintain BP≥140/80. Citicoline was also shifted to 100mg/ml suspension, 2ml /NGT TID. Other meds were continued. Vital signs and neuron vital signs were monitored with CBG monitoring every 8 hours. ON the 4th hospital day, the patient was maintained on NGT and Oral feeding was continued. CXR PA and CBC with platelet count were also done.Hydralazine was increased to 25μgtts/min. Mannitol tapering was done, 100cc TIV q6 x 24 hours then 100cc TIV q8 hours, then 100cc TIV q 12 hours x 24 hours then 100 cc TIV q24hours then discontinue.Dexamethasone was also tapered to 15 mg TIV q12 x 3 days then 5mg TIV OD x 3 days. Other meds were continued. Vital signs and neuron vital signs were monitored with CBG monitoring every 8 hours. Secretions were suctioned regularly. ON the 5th hospital day, the patient was maintained on NGT and Oral feeding was continued. CXR PA and CBC with platelet count were also done. ABG and CBC with PC were done. Ceftriaxone 1gm TIV q12 ANST, Azithromycin 2gm per NGT as single dose, and ERdosteine 3oomg.cap per NGT TID were started. MAnnitol and Dexamethasone tapering were continued. Other med were continued. Vital signs and neuron vital signs were monitored with CBG monitoring every 8 hours. Secretions were suctioned regularly. On the 6th hospital day, the patient was maintained on NGT and Oral feeding was continued. Medications were continued. Vital signs and neuron vital signs were monitored with CBG monitoring every 8 hours. Secretions were suctioned regularly. ON the 7th hospital day, te patient was maintained on NGT and Oral feeding was continued. CBC with PC, Na ,K, Blood GS/CS and sputum GS/CS were also done.Citicoline 100mg/ml was shifted to 5cc q6 then into Citicoline 500mg/cap, 2 capsules q6 per NGT. Enalapril + HCTZ 12.5 mg/tab OD in AM and Metoprolol 50 mg tablet, ½ tab BID/NGT. In the afternoon, the result of K was noted to be low hence the following meds were started: Calcium gluconate, 1 vial + sterile water SIVP as single dose, D50-50 Water + 10 units regular insulin x 3 doses, 6 hours apart and Salbutamol nebulization , 1 neb q4 .12 L ECG was also done. Other medications were continued. Vital signs and neuron vital signs were monitored with CBG monitoring every 8 hours. Secretions were suctioned regularly. On the 5th hospital day, the patient was maintained on NGT and Oral feeding was continued. 12L ECG, Na, K, Cl were also done. Medications were continued. Vital signs and neuron vital signs were monitored with CBG monitoring every 8 hours. Secretions were suctioned regularly.

Urinaly Urobilinogen Protein pH Blood Hemoglobin Specific gravity Ketone Bilirubin Glucose RBC Pus cells Squamous epithelial cell Bacteria Amorphous urates Mucus threads

Negative Negative 5.0 +1 Negative 1.010 Negative Negative Negative 2 – 4/hpf 0 – 1/hpf Rare Rare Occasional occassional


				
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