CASE NO.

1:
CVD
PASAY CITY GENERAL
HOSPITAL
ECHAVEZ, HYNNE JHEA O.
EAY, KATRINA ANDREA C.
ECIJA , CLYDE JOSHUA A.
PRECEPTOR: DR. MORILLO
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
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. But they then
decided for transfer to Pasay City General Hospital their
hospital of choice hence then consulted and was
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 8 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
 Known illicit drug user of methamphetamine/shabu last used
documented 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.
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.
 CHEST AND 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 decreased breath sounds on both lung field.
Negative for bronchopony, egopony and whispered pectoriloquy.
 CARDIOVASCULAR
 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 5th 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.
 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.
SPINE AND 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

 The patient is conscious, oriented to time,

place and person. The patient has no
dysarthria, and can follow simple commands.
 Memory – Intact immediate, recent, and
remote memory
 Repetition – Patient was able to repeat the
words fluently and without pauses.
Cranial Nerves
 CN I- not assessed
 CN II- 2-3 mm pupils,equally reactive to light
 CN II & III Pupils are equally round, reactive to light and accommodation.
Responds to both direct and consensual reflex.
 CN III, IV &VI– Normal EOM Movement, negative for nystagmus
 CN V- Sensory: patient can identify a sharp object from a blunt object
 CN VII – (-) Facial asymmetry
 CN VIII – Patient can hear whispered sounds in both ears
 CN IX & X – Uvula is in midline
 CN XI – Patient is able to move shoulders against resistance, shrugs shoulders
and rotate head against resistance with some difficulty
 CN XII – Tongue is at the midline, but no fasciculation, no atrophy and can
move tongue from side to side.
Motor Test
 No noted fasciculation, atrophy of muscles on both upper and
lower extremities. Muscle tone is normal with no noted spasticity
and rigidity on both lower and upper extremities. Motor function
grade of 4+ upper extremities and 2+ on the lower extremities
Cerebellar Test
 NOT ASSESSED
Sensory Examination
 Patient has increased sensation on both right and left lower
extremities. Upper extremities has intact sensation.
Meningeal Signs
 Negative for nuchal rigidity, Kernig’s and Brudzinski’s sign
CLINICAL IMPRESSION:

Cerebrovascular Disease
STROKE
SALIENT FEATURES:
 64 year old, Male
 Hypertensive
 Loss of Consciousness
 Smoker for 30 years 2 packs a day
 Occasional alcoholic beverage drinker
 Use of illicit drugs methamphetamine
 Sedentary lifestyle
DIFFERENTIAL DIAGNOSIS
Hypoglycemia
Rule In Rule Out

 Loss of  Tremor
consciousness  Paresthesia
 Tachycardia  Diaphoresis
 Weakness  Pallor
DIFFERENTIAL DIAGNOSIS
Migraine with Aura
Rule In Rule Out

 Loss of  Sensitivity to light

consciousness  Nausea and
 Headache vomiting
 Gradual onset
 Visual disturbances
DIFFERENTIAL DIAGNOSIS
Seizure Disorder
Rule In Rule Out

 Stiffening of upper  No history of

extremities seizure
 Upward rolling of  No EEG
eyeballs
 Headache
PERTINENT POSITIVES
 Upward rolling of eyeballs
 Stiffening of extremities
 Decerebration
 Loss of consciousness
 Hypertensive
 Headache
 Smoker
 Alcohol drinker
 Illicit drug use
PERTINENT NEGATIVES
 Vomiting
 Nausea
History of stroke
Aphasia
CLINICAL WORKUP
Complete Blood Count
Lipid Profile
Coagulation studies
Glucose and Electrolyte test
ECG
Carotid/ Doppler Ultrasound
DIAGNOSTIC EXAM
1.Plain CT Scan
• initial neuroimaging of choice to differentiate ischemic and hemorrhagic
stroke; excludes stroke mimickers; highly sensitive in detecting hemorrhage;
• CT findings in the hyper acute phase (look for early signs of infarction):
gray-white matter differentiation loss, insular ribbon sign,
dense middle cerebral artery sign, lentiform nucleus
obscuration, sulcal effacement.
DIAGNOSTIC EXAM
CT SCAN
DIAGNOSTIC EXAM
2. Cranial MRI
•better imaging for posterior circulation ischemic strokes; acute infarcts
are seen as bright signals on DWI sequence with corresponding low-
intensity signals on ADC map
•more expensive, not that sensitive in detecting acute
hemorrhages, less widely available, contraindicated in patients with
metallic implants
TREATMENT
APPROACH CONSIDERATIONS:
Management begins with stabilization of vital signs.
Perform endotracheal intubation for patients with a decreased level
of consciousness and poor airway protection.
Intubate and hyperventilate if intracranial pressure is elevated, and
initiate administration of mannitol for further control.

Rapidly stabilize vital signs, and simultaneously acquire an

emergent computed tomography (CT) scan. Antacids are used to
prevent associated gastric ulcers.
TREATMENT
A.Medical treatment
1.Blood pressure management
• treat if SBP > 180 mmHg
• acute lowering of SBP <140mmHg within 7 days is safe in non-surgical
patients
• SBP >220mmHg or DBP > 120mmHg :LABETALOL 10-20mg IV for 1-
2min; dosing repeated/doubled every 1Omin to a max dose of 300mg
 TREATMENT
2. Manage Increased Intracerebral Pressure
- Head elevation - 30-45 degrees
• Osmotic Therapy - Mannitol 20% IV infusion (0.5-1.5g /kg every 3-6 hours),
Hypertonic saline(target Na 145-155 mmol/L)
• Serum Osmolality - maintain at 300-320 mosmol/kg
• Hyperventilation - target pCo2 of 30-35mmHg, only for acute severe
neurological decline from brain swelling as a bridge to more definitive therapy
 TREATMENT
3. Other aspects of management
-control seizures(diazepam)
• ensure neuroprotection
• maintain adequate nutrition and fluid and electrolyte balance
• stool softeners
• DVT prophylaxis, early rehabilitation once stable, and bedsore
precautions
 B. SURGICAL TREATMENT
OTHER PATIENTS WHICH MAY BENEFIT
IMMEDIATE SURGICAL CANDIDATES
FROM SURGERY
• Cerebellar hemorrhage >3 cm with
neurologic deterioration or brainstem
deterioration or brainstem compression
and hydrocephalus from ventricular
obstruction • Basal ganglia or thalamic
hemorrhage
• Bleed from structural lesions(AVM,
Aneurysms) • GCS 5 and above
• Clinically deteriorating young patients • Supratentorial hematoma with
with moderate or large lobar hemorrhage volume >30 cc

• Ventricular drainage for intra ventricular

hemorrhage with moderate to severe
hydrocephalus
 END….

ECHAVEZ, HYNNE JHEA O.

EAY, KATRINA ANDREA C.
ECIJA , CLYDE JOSHUA A.