Fernandez_ Teresita 48 hour

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					OSPITAL NG MAYNILA MEDICAL CENTER DEPARTMENT OF INTERNAL MEDICINE

Name: Fernandez, Tessie Age/Sex: 51/F Address: 397-B Hipodromo St. Sta. Manila Date of Admission: July 7, 2007, 11:00 am Admitting Diagnosis: Primary Seizure disorder Anemic probably result of pathology Final Diagnosis: --Residents-in-charge: Drs. Dalanon/Gutierrez/Gregorio Clerks-in-charge: Ocampo G/ Patayan/Roque

Hospital #: 1707178 Room #: 428 Date of Discharge:

48 Hour History This is a case of a 51 year old female of Sta. Ana, Manila, who was came in due to convulsions. History of Present Illness The patient is a diagnosed case of seizure disorder maintained on Phenytoin 100mg/day but stopped fully, months ago. Her last attack was more than 1 year ago. Three days prior to admission, patient had undocumented fever which occurred on and off with accompanying difficulty of breathing. She has no abdominal pain, no change in bowel movement, no hematuria and no oliguria. She then consulted to a private clinic where she was given unrecalled antibiotics. Eight hours prior to admission, while at rest, patient had generalized stiffening accompanied by upward rolling of eyeballs and drooling of saliva which lasted for less than a minute. There was no loss of consciousness and headache. Patient was brought to UERM but was not admitted there because there were no rooms available. Thus the relatives transferred to another hospital, hence the admission. Past Medical History No HPN, no DM, no previous hospitalizations Family History Known history of hypertension and liver CA on paternal side Personal/Social History: Non-smoker Non alcoholic beverage drinker Review of Systems: General: no weight loss, no loss of appetite HEENT: no tinnitus, no blurring of vision, no dysphagia Respiratory: with occasional cough, no cold, no difficulty breathing Cardiovascular: no chest pain, no PND, no palpitations, no orthopnea, with easy fatigability Endocrine: no polyuria, no polyphagia, no polydipsia Hematologic: no easy bruisability Physical Examination: Patient is conscious, coherent, not in cardiorespiratory distress o Vital Signs BP: 130/80 HR: 80 bpm RR: 20 cpm Temp: 36 C HEENT: anicteric sclerae, pale palpebral conjuctiva, no naso-aural discharge, no palpable cervical lymph nodes, no neck mass, no tonsillopharyngeal congestion, no neck vein distention Chest and Lungs: Symmetrical chest expansion, no retractions, clear breath sounds Heart: Adynamic precordium, normal rate, regular rhythm, no murmurs Abdomen: Flat, normoactive bowel sounds, soft, (+) direct tenderness on hypogastric area Extremities: grossly normal, no cyanosis, no edema, full equal pulses Neurologic: conscious, coherent, oriented to time, person and place. CN I – can smell CN II – intact visual fields CN III, V, VI - EOM, intact, pupils 2-3 mm CN V – with bilateral corneal reflex CN VII – no facial asymmetry

CN IX, X – good gag reflex CN XI – can shrug shoulders equally CN XII – tongue midline on protrusion
Sensory Motor Deep tendon reflexes

100%

100%

4/5

4/5

++

++

++ 100% 100% 4/5 4/5

++

No nuchal rigidity No Babinski reflex No Kernigs sign Assessment: Plan: Primary seizure disorder

for Admission

Course in the Wards: Upon admission, the following diagnostics were requested: CBC with PC, Urine analysis, CXR-PA, 12 lead ECG, FBS, Serum Blood urea nitrogen, creatinine, sodium ans potassium, HDL, LDL, TG, and Total cholesterol. She was also scheduled for ultrasound of the whole abdomen. Cranial CT scan with contrast was also requested. The following therapeutics were ordered: Phenytoin 100mg thrice a day per orem and Diazepam 5 mg through IV as needed given during active seizure. She was put to low salt, low fat diet and positioned at moderate to high back rest with strict input and output monitoring. Vital signs were monitored every 2 hours including the neurologic vital signs. CBG was monitored also every 6 hours. Oxygen support was also given. Blood that is properly typed and crossmatched should also be transfused immediately. She was watched out for active seizure. st On the 1 hospital day, patient did not have any episodes of seizure, no headache, no vomiting, no difficulty of breathing, no chest pain, no edema, but has vough. Her BP=110/70, CR=80, RR=18. Upon PE, she had pink palpebral conjunctiva, anicteric sclera, no retractions. Abdomen is flat with normoactive bowel sounds, soft and non-tender. Present working impression is now primary seizure disorder to consider chronic kidney disease. She was still for cranial CT scan with contrast, ABG, serum Calcium, phosphate, and urinalysis. Serum Creatinine and Potassium were repeated. Medications were reviewed, drugs given were Phenytoin 125 mg/ml, 5 mL TID and Diazepam 5 mg/IU as needed foractive seizures. She was still for Blood transfusion, 2 units of packed RBC propertly typed and crossmatches. Vital signs were monitored every 2 hours, including the input and output of the patient. CBG was monitored every 6 hours. She was watched for active seizure, chest pain and difficulty of breathing. nd On the 2 hospital day, patient had no episodes of seizure, no headache, no vomiting, no difficulty of breathing, and no fever. Her vital signs were BP=130/70, HR of 73, RR of 20 and T=36.1. She has pink palpebral conjunctiva and anicteric sclera. Working impression was changed to primary seizure disorder, hypokalemia probably secondary to 1. RTA, t/c acute renal failure. Hence plan was to increase her potassium diet. Diagnostics ordered were ultrasound of the whole abdomen, and 24-hour urine potassium. Cranial CT scan and ABG was not done hence were ordered again. She was started on NaHCO3 tab, 1 tab three times a day and ferrous sulfate tablet, 1 tab twice a day. Her other medications were continued. She was still for Blood transfusion. Other management were continued. At 7:00 pm, patient was started on acetyl- sachet, 1 sachet to be dissoled in a glass of water to be given three timed a day. Sodium bicarbonate, 36 meq + 3 equal amounts of diluted water was also given via slow IV push after repeat ABGs. Hemodialysis was also considered.


				
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