Echavez, Hynne Jhea O.

HISTORY # 1

Patient Name: Magsaysay Eusebio Preceptor: Dr. Morillo

Informant: Edgar Eusebio Date of History: Feb 03, 2020
Reliability: 80% Date of Submission: Feb 07, 2020
Historian: Echavez, Hynne Jhea O. Section B- Group 23

I.GENERAL DATA
Patient M.E, 64 years old, Male, Single, Roman Catholic, Unemployed, residing at
Eusebio Street, Barangay 43, Pasay City. Born on August 31, 1951 in Pasay City.
Admitted for the first time in Pasay City General Hospital last January 27, 2019.

II.CHIEF COMPLAINT: Loss of consciousness

III.HISTORY OF PRESENT ILLNESS:

Five hours prior to consult the patient was noted to have upward rolling of the eyeballs
and stiffening of extremities in decerebrate manner, loss of consciousness caused him
to fall on his right side directly to the ground , the patient was rushed to the private
hospital and CT-Scan was taken and was managed . They then decided for transfer to
Pasay City General Hospital their hospital of choice hence was consulted and admitted.

IV.PAST MEDICAL HISTORY:

According to the informant the patient had complete immunization. During childhood
had history of having measles, mumps, and chicken pox during elementary school. He
has no known allergies to food, drugs, pollens and dust. Diagnosed hypertensive with
prescribed drug of Amlodipine and Losartan but does not take his maintenance
regularly. No other illnesses like Asthma, DM, TB, Arthritis, Cancer, Gastrointestinal
disease and Renal disease. He has no history of prior hospitalizations and this is his
first admission. No history of accidents, never had surgery, and no history of blood
transfusion.

V.FAMILY MEDICAL HISTORY:

Both parents are diagnosed hypertensive. He has 7 siblings all are hypertensive and 2
already dead with unrecalled cause. Family has no history of cancer, stroke, DM,
asthma, TB, Blood disorders, seizure, epilepsy, gallbladder disease and mental illness.
Though some relatives has history of gout and arthritis.

VI.PERSONAL AND SOCIAL HISTORY:

Patient M.E, is a high school graduate. Never experienced working had always been
unemployed. He is single and has no children. Sleeps 7 hours a day. He eats 3 times a
day, he loves to eat rice poured with coffee and other than that he eats whatever is
available, drinks 2 cups of coffee a day, does not take food supplements. He has a
sedentary lifestyle and usually just stays at home or sits outside of his house. Doesn’t
exercise. An occasional alcohol beverage drinker, ex-smoker can finish 2 packs/ day
last use 2019 approximately smoked for total of 30 years, and illicit drug user
methamphetamine/ shabu last documented used in year 2010. He gets financial support
from his siblings. And is currently living by in the first floor of his brother’s 2 storey
house. His place is well ventilated, with 2 windows, 1 comfort room, and 1 bedroom.
Has water supply from Maynilad and drinks tap water. He has no pets. And garbage is
collected weekly by the municipal garbage truck.

VII.OBGYNE HISTORY: Not applicable

VIII. REVIEW OF SYSTEMS: (+ if present, - if absent)

General: (-) Fever, (-) Fatiguability, (-) Chills, (+) Weakness, ( +) Weight Change
Integuementary: (-) Pruritus, (-) Pigmentation/texture change, (-) Tenderness, (-) Nail
changes, (-) Hypopigmentation, (-) Skin turgor
Head and Neck:
Head and eyes: (+) Headache, (-) Diplopia, (-) Blurring of vision, (-) Eye redness, (-)
Dizziness, (-) Eye itchiness, (-) Head injury, (-) Photophobia, (-) Eye pain
Ears: (-) Ear pain, (-) Vertigo, (-) Hearing loss, (-) Tinnitus
Nose: (-) Nasal discharge, (-) Disturbance of smell
Mouth, Throat and Pharynx: (-) Sore throat, (-) Gingivitis, (-) Hoarseness, (-) Sore
tongue, (-) Disturbance of taste, (-) Dysphagia
Neck: (-) Neck pain, (-) Lumps, (-) Swollen glands
Respiratory: (-) Dyspnea, (-) Orthopnea, (-) Chest pain, (-) Sputum, (-) Back pain, (-)
Cough, (-) Hemoptysis
Cardiovascular: (-) Chest pain, (+) Easy fatigability, (+) Palpations, (-) Shortness of
breath, (-) Edema
Gastrointestinal: (-) Poor appetite, (-) Dysphagia, (-) Odynophagia, (-) Nausea, (-)
Vomiting, (-) Hematemesis, (-) Abdominal enlargement, (-) Abdominal pain, (-) Reflux,
(-) Epigastric pain
Bowel Elimination: ( ) Regular (every ), (-) Diarrhea, (-) Constipation, (-) Abdominal pain,
(-) Flatulence, (-) Steatorrhea, (-) Melena, (-) Hematochezia
Genitourinary: (-) Dysuria, (-) Oliguria, (-) Hematuria, (-) Incontinence, (-) Passage of
stones, (-) Nocturia, (-) Polyuria, (-) Anuria, (-) Discharge, (-) Flank/Suprapubic pain, (-)
Dribbling
Musculoskeletal: (+) Muscle pain, (-) Joint pain and stiffness, (-) Swelling, (+)
Weakness, (-) Atrophy, (-) Contractures, ( +) Restriction of motion, (-) Cramps, (-)
Hypertrophy
Neurologic: (+) Syncope, (-) Seizure, (+) Weakness (-)paralysis, (+) Headache, (-)
Tremors, (-) Loss of memory, (-) Depression, (-) Delirium, (-) Hallucination, (-)
Numbness
Endocrine: ( +) Weight change, (-) Heat or cold incontinence, (-) Polyuria, (-) Polydipsia,
(-) Polyphagia, (-) Abnormal growth
Hematologic: (-) Easy bruisability, ( -) Easy fatigability, (-) Pallor, (-) Bleeding
Peripheral: (-) Claudication, (-) Varicose veins
Psychiatric: (-) Nervousness, (-) Anxiety, (-) Depression, (-) Hallucinations
IX. PHYSICAL EXAMINATION

GENERAL SURVEY:
Patient is alert, coherent, cooperative. Has medium body built appears under nourished
and is well kept. Posture and gait not assessed as patient is not ambulatory. No gross
deformities, afebrile and not in cardiorespiratory distress.

VITAL SIGNS:
Blood pressure:150/80 mmHg
Heart rate: 80 bpm
Respiratory rate: 18 bpm
Temperature: 36.7 C

HEENT:
 Hair: black in color, abundant, well-distributed, smooth texture; scalp slightly
mobile along cranium, no masses or tenderness upon palpation; no lice, flaking
or lesions were noted.
 Cranium: normocephalic, symmetrical; no deformities, temporal arteries not
visible but palpable, with moderate pulsations. No wound noted from the fall of
the patient.
 Face: oval, symmetrical; no facies; patient can move facial muscles with ease,
good facial profile.
 Eyes: eyebrows thin, black, well-distributed, symmetrical; eyelashes black, short,
oriented upward, outward, no matting; eyelids normal, symmetrical, no ptosis or
edema, no lesions; pale palpebral conjunctivae, no lesions; anicteric sclera;
cornea transparent; iris brown in color; pupils symmetrical, 2-3mm diameter.
 Ear: normal, triangular in shape, symmetrical, no lesions, deformities or
tenderness; both external auditory canals have cerumen, cerumen not impacted
 Nose: nose symmetrical, bridge depressed, symmetrical; no flaring of all nasi;
patent vestibule with short vibrissae; mucosa pinkish in color, no swelling,
lesions, secretions or bleeding; nasal septum midline, no perforations.
 Mouth and Throat: The lips are brownish, symmetrical and dry with no lesions, no
pigmentation and no ulcers noted. Buccal mucosa is pale and dry, and the gums
are pink with no bleeding or recession. Incomplete set of teeth with dental
carries. The tongue is in the midline, pink and there is no fasciculation or sores
noted. Pharynx without exudates and uvula is in the midline.
 Neck: no deformities, trapezius and sternocleidomastoid muscles well-
developed, no deviations, no tenderness, trachea is on the midline; thyroid gland
not palpable; no cervical lymphadenopathy upon palpation.

CVS:
  Upon inspection the skin is fair, no scars, lesions or areas of pigmentations
noted. Precordium is adynamic. No bulging or depressions noted. No visible
pulsations or prominent vessels. Carotid artery is not visible but palpable,
symmetrical, regular rhythm. No neck vein distention.
 Upon palpation the PMI is strong, palpated at the 5 th ICS LMCL. Negative for
thrills, lifts, or heaves.
 Upon auscultation the heart rate is 80 beats per minute characterized as normal
and regular in rhythm. S1 is heard loudest at the apex, and S2 is best heard at
the base. Physiologic splitting. S3 and S4 heart sounds not appreciated. No
murmurs heard upon auscultation. Brachial, radial, popliteal, posterior tibial and
dorsalis pedis are bilaterally palpable and brisk, with normal rate and regular
rhythm without thrills or bruits.

CHEST/LUNGS:
 The skin is brown in color. No visible subcutaneous blood vessels with normal
muscle development. No visible contraction of accessory muscles of respiration.
No visible nodules, chest hair nor scars noted. The bony thorax is elliptical in
shape, symmetrical with no gross deformities such as pectus carinatum and
pectus excavatum. The anteroposterior (AP) diameter is 2/3 of transverse
diameter.
 The respiratory rate is 18 cycles per minute with normal depth and rhythm. The
inspiration is longer than expiration with effortless breathing. Symmetric chest
expansion, no bulging and widening of the ICS without chest lagging.
 Upon palpation, no swelling, tenderness and masses noted. Chest expansion is
symmetrical. Equal but weak tactile fremitus on both lung fields.
 Upon percussion on anterior and posterior chest, resonance was noted on both
lung fields.
 Upon Auscultation, there is normal vesicular breath sounds on both lung field.
Negative for bronchopony, egopony and whispered pectoriloquy.

ABDOMEN:
 Abdomen is flat, and symmetrical, skin is light brown, no superficial veins, striae
and abnormal pigmentations and scars seen. No bulging, visible pulsations or
peristalsis noted. Umbilicus is inverted.
 Measured at 28.5 inches at the level of umbilicus. Bowel sounds heard at 20 per
minute best heard at the left upper quadrant area. No bruits heard over the
abdominal aorta, as well as the right and left iliac vessels.
 Upon palpation, abdomen is soft, non-tender, and has no palpable masses. No
tenderness on light and deep palpation.
 Liver edge is non-palpable. Upon percussion, the abdomen is generally
tympanic. Liver span is measured at 10cm.
 No splenic dullness appreciated in the Traube’s space. The patient is also
negative for Psoas, Obturator, Rovsing’s and Murphy’s sign. The patient is also
negative on tests for ascites such as fluid wave and shifting dullness.
Costovertebral angle tenderness not assessed as the patient cannot sit up.
EXTREMITIES:
 UPPER EXTREMITIES
Hands, Wrists, Fingers
 Difficulty in full range of motion (flexion, extension, adduction, abduction,
apposition)
 No ulnar or radial deviation of wrists
 No swelling, masses, tenderness
 Nails show no clubbing
Shoulder
 Difficulty in full range of motion (abduction, adduction, external and internal
rotation)
 Arms
 Difficulty in full range of motion (flexion, extension, pronation, supination)
 Muscles are symmetrical, no atrophy
 No swelling, masses, tenderness
SPINE
 No deviations or deformities
LOWER EXTREMITIES
 Hip Joint
 Difficulty in full range of motion
 Knee Joint
 Difficulty in full range of motion (flexion, extension)
 No crepitus, masses, or nodules
 Patella- no ballotement, not moveable
 Ankle Joint, Feet
 Difficulty in full range of motion (dorsiflexion, plantar flexion, inversion, eversion)
 No tenderness, crepitus
 No deviation of big toe

NEUROLOGIC EXAM

GCS Score :13

E4V5M2

Cerebral Function:
- Oriented to time, place and person
- Able to follow simple commands
- Intact immediate, recent and remote memory.

Motor Function: No muscular atrophy, no tremors noted. Motor function grade of 4+

upper extremities and 2+ on the lower extremities

Sensory examination: Patient has increased sensation on both right and left lower
extremities. Upper extremities has intact sensation.
Reflexes:
Deep tendon reflexes are normal. Biceps, triceps, knee, and ankle reflexes are 2+.
Patient negative for Babinski and Chaddock reflex.

Cerebellar Function:
Not performed

Meningeal Signs: Negative for nuchal rigidity, Kernig’s and Brudzinski’s sign

Cranial Nerves:
CN I- not assessed
CN II- 2-3 mm pupil, positive direct and consensual reaction to light
CN III, IV, VI- extraocular muscle movement intact
CN V- intact sensory function over the face
CN V, VII- positive corneal reflex
CN VII- negative for facial asymmetry
CN VIII- intact hearing
CN IX, X- uvula midline; pharyngeal walls rise symmetrically upon phonation and
stimulation of the gag reflex; no hoarseness noted or vocal anomalies
CN XI- can shrug shoulders with some difficulty, no gross muscle atrophy
CN XII- tongue in the midline, no apparent deviation upon protrusion; no fasciculation or
atrophy noted

X. CLINICAL IMPRESSION:
CEREBROVASCULAR DISEASE
STOKE

XI. SALIENT FEATURES / BASIS OF DIAGNOSIS:

- Hypertensive
- Age 64 y/o
- Upward rolling of eyes and stiffening of extremities
- Does not take his medications regularly
- Sedentary lifestyle/ physical inactivity
- Past cigarette smoker
- History of illicit drug use
- Alcohol beverage drinker
-
XII. DIFFERENTIAL DIAGNOSIS:

Differential Diagnosis Rule In Rule Out

Transient Ischemic Attack - Sudden loss of - No trouble in vision
consciousness for both eyes
- Weakness of - No trouble speaking
extremeties and understanding
 - History smoking, - Symptoms did not
drug use, alcohol resolve immediately
beverage drinker as seen in TIA
- Hypertensive
- Physical inactivity
Hypertensive Emergencies - Hypertension - Severe chest pain
- Headache - Shortness of breath
- Unresponsiveness/
Loss of
consciousness
- Seizure
Migraine - Headache - No hypersensitivity
- Loss of to light and sound
consciousness - No nausea and
vomiting

XIII. PERTINENT POSITIVES AND NEGATIVES:

Pertinent Positives Pertinent Negatives
- loss of consciousness - nausea
- hypertension - vomiting
- severe headache - no abnormal visual fields
- rolling of eyeballs - aphasia
- stiffening of extremities (decerebrate) - slurring of speech
- loss of consciousness
- weakness of the extremities
- history of illicit drug use
- history of smoking
-alcohol beverage drinker

XIV. CLINICAL WORK-UP:

Laboratory and Imaging tests I would request:
 Capillary Blood Glucose
 Arterial Blood Gas
 Complete blood count
 Serum Electrolytes
 Liver Function Test
 Kidney Function Test
 Coagulation studies (prothrombin time or international normalized ratio [INR] and
an activated partial thromboplastin time)
 CT Scan
 MRI

TREATMENT PLAN:
Approach Considerations
 The treatment and management of patients with STROKE
depends on the cause and severity. Basic life support, as well as
control of bleeding, seizures, blood pressure (BP), and intracranial
pressure, are critical.

Management begins with stabilization of vital signs.

1. Perform endotracheal intubation for patients with a decreased

level of consciousness and poor airway protection.
2. Intubate and hyperventilate if intracranial pressure is elevated,
and initiate administration of mannitol for further control.
3. Rapidly stabilize vital signs, and simultaneously acquire an
emergent computed tomography (CT) scan.
4. Glucose levels should be monitored, with normoglycemia
recommended.
5. Antacids are used to prevent associated gastric ulcers.
6. Neuroprotection - The 5 “H” Principle avoid hypotension,
hypoxemia, hyperglycemia or hypoglycemia and hyperthermia

Emergency treatment of stroke focuses on controlling the bleeding

and reducing pressure in your brain caused by the excess fluid. For our
patient

- Complete evaluation

- Assess ABCs (Airway, Breathing, Circulation)

- Establish time of onset

- Obtain IV access and blood samples

- Provide oxygen if hypoxemic

- Check glucose. Correct hypo or hyperglycemia

- Obtain 12 L ECG

- Neuroimaging

MEDICATIONS TO BE USED:

 Mannitol - 150cc TIV q6

 Osmotic diuretics, such as mannitol, may be used to decrease
intracranial pressure in the subarachnoid space. As water
diffuses from the subarachnoid space into the intravascular
compartment, pressure in the subarachnoid compartment may
decrease. Mannitol reduces cerebral edema with the help of
osmotic forces. It also decreases blood viscosity, resulting in
reflex vasoconstriction and lowering of intracranial pressure.
 Omeprazole – 40 mg TIV OD
Proton pump inhibitor to prevent patient from having gastric
ulcers
 Losartan – 100 mg/tab OD AM
It blocks the vasoconstrictor and aldosterone-secreting effects
of angiotensin II. It may induce a more complete inhibition of the
renin-angiotensin system than ACEIs do. In addition, it does not
affect the response to bradykinin and is less likely to be
associated with cough and angioedema.
 Metoprolol- 50mg/tab q12
Metoprolol selectively inhibits β1-adrenergic receptors but has
little or no effect on β2-receptors except in high doses. It does
not exhibit membrane stabilising or intrinsic sympathomimetic
activity.
 Amlodipine – 5mg/tab OD PM
Calcium channel blockers are used to lower BP by relaxing the
blood vessels and increasing the amount of blood and oxygen
that is delivered to the heart, while reducing the heart’s
workload. In acute situations, intravenous calcium channel
blockers are frequently used to control BP. These are first-line
agents for long-term BP control in stroke patients (along with
thiazides, ACEIs, and angiotensin receptor blockers [ARBs]).
 Diazepam- 5mg TIV
Benzodiazepines to control and prevent seizure activity. Diazepam is a long-
acting benzodiazepine that exerts anxiolytic, sedative, anticonvulsant, muscle
relaxant and amnestic effect. It binds to stereospecific benzodiazepine receptors
on the postsynaptic gamma-aminobutyric acid (GABA) neuron in different regions
of the central nervous system, e.g. brain and spinal cord thereby, increasing the
inhibitory effects of GABA which is involved in sleep induction, control of
hypnosis, memory, anxiety, epilepsy and neuronal excitability.
 Phenytoin- Anticonvulsants prevent seizure recurrence and
terminate clinical and electrical seizure activity. These agents
are used routinely to avoid seizures that may be induced by
cortical damage. Effect  is not immediate so concomitant
 administration of an intravenous benzodiazepine will usually be
necessary to control status epileptic.
 Acetazolamide – 250mg tab via NGT q8
Diuretic and anti-epilepsy drug. Acetazolamide reversibly inhibits
the carbonic anhydrase enzyme leading to reduced hydrogen ion
secretion at renal tubules and increased renal excretion of Na, K,
bicarbonate and water. It also decreases the production of
aqueous humour in the eyes to reduce intraocular pressure (IOP)
and inhibits carbonic anhydrase in the CNS to retard abnormal
and excessive discharge from CNS neurons.
 Leviteracetam – 500mg 1 tab OD
For partial seizures w/ or w/o secondary generalisation;
myoclonic seizures (w/ juvenile myoclonic epilepsy); primary
generalised tonic-clonic seizures (w/ idiopathic generalised
epilepsy)

DISCHARGE

Recovery from a stroke

The duration of recovery and rehabilitation depends on the severity of the stroke and
the amount of tissue damage that occurred. Different types of therapy may be involved,
depending on your needs. Options include physical therapy, occupational therapy, or
speech therapy. The primary goal of therapy is to restore as much function as possible.
Your outlook for recovery depends on the severity of the stroke, the amount of tissue
damage, and how soon you were able to get treatment. The recovery period is long for
many people, lasting for months or even years. However, most people with small
strokes and no additional complications during the hospital stay are able to function well
enough to live at home within weeks.

Preventing recurrence of stroke

There are certain risk factors for a hemorrhagic stroke. If you can avoid these factors,
you reduce your odds of experiencing one. High blood pressure is the most likely cause
of an ICH. Keeping your blood pressure under control is the best way to control your
risk. Talk to your doctor about how to lower your blood pressure if it’s too high.

Alcohol and drug use are also controllable risk factors. Consider drinking in moderation
and avoid any type of drug abuse. Blood thinners help prevent ischemic strokes but can
also increase your odds of having an ICH. If you are on blood thinners, be sure to speak
to your doctor about the risks