Patients BackgroundPersonal Data Name of Patient: Mr.

X Age: 64 y/o Status: Married Sex: Male Admitting Diagnosis Final Diagnosis Past Medical History Vital Signs T = 37.5 C :T/C Sepsis S/S CVA :CVA ( Cerebrovascular Accident) :Hypertension, DM Type II :BP = 130/80 ; PR = 72 ; RR = 22 ;

Brief History: The patient has been bedridden since he had stroke last April 2007, he also had difficulty in swallowing and have a necrotic ulceration at the sacrum and olecranon prior to admission. Mr. Ex-Men had a sedentary lifestyle, he loves eating fatty foods and food with high calories, he also have a family background on hypertension. He only stays at home and doesnt exercise. In 1987, he also had stroke due to hypertension, but didnt take any maintenance drug after that. He only takes Calcibloc 10mg, whenever he feels the signs and symptoms of hypertension. Review of Systems - Physical Assessment Vital signs : T 37.5 C PR 72 RR 22 BP 130/80

Consciousness : obtunted open eyes, responds slowly, confused Bed-ridden Hemi paresis - left side of the body Wt: 47 kgs. Ht: 5 5 Weight ( loss [+] gain [ - ] ) Fever [ - ] Night Sweats [ - ] Significance: weight loss of about 4-5 kgs.

SKIN Change in color [ - ] , Ulcers [ + ] ,Rashes [ - ] , Pruritus [ - ] , Bruising [-],

Nevi ( change in color [ - ] / shape [ - ] / size [ - ] ) Significance: Sacrum - stage 3 decubitus ulcer (ulcer extends to

subcutaneous fat layer) , Olecranon process of ulna stage 2 decubitus ulcer (skin is broken to epidermis, abrasion and blister present) Oxygen is given via nasal canula at 2-3 lpm to deliver more oxygen to blood

enhance wound healing HEAD oily [ + ] EYES Change in visual field [ - ] , Glasses [ - ] , Diplopia [ - ] , Inflammation [ -], Significance: oily hair need to improve hygiene Headache [ - ] , Injury [ - ] , Tenderness [ - ] Hair & scalp condition ( infection/ infestation) [ - ], texture silky [ - ] ,

Discharge [ - ] NOSE Allergies [ - ] , Sinus problem [ - ] , Obstruction [ - ] , Polyps [ - ] , Discharge [ - ], Epistaxis [ - ] Significance: none Throat Toothaches [ - ] , Loose teeth [ - ] , Dentures [ - ] , Bleeding gums [ - ] , Mouth sores [ - ] , Difficulty in swallowing [ + ] , Ulceration or lesion on Significance: none

tongue, gums, buccal mucosa [ - ] Significance: NG tube feeding

Respiratory Chest pain [ - ] , Dyspnea [ + ] , Cough [ - ] , Amount and color of sputum

[ - ] , Hemoptysis [ - ] Significance: Ventilation machine Oxygen is given via nasal canula at 2-3 lpm to ease labored breathing

Cardiovascular Chest pain / pressure / tightness [ - ] , Orthopnea [ + ] , Claudication [ ] Significance: Bed reclined to ease breathing

Gastro-Intestinal Dysphagia( solid & fluid ) [ + ] , Ulcer [ - ] , GERD [ + ] , Indigestion [ - ] ,

Diarrhea, Constipation [ - ] , Blood in stool [ - ] , Hemorrhoids [ - ], Jaundice [ - ] Significance: NG tube feeding Genito-Urinary Dysuria / Hematuria / Nocturia [ - ] , UTI [ - ] , Incontinence [ +/- ] Significance: Bed reclined to ease breathing

Endocrine Heat / Cold tolerance [ - ] , Weight change [ + ] , Polydisia [ - ] , Polyuria [ - ] ,

Polyphagia [ - ] Significance: Weight loss of about 4-5 kgs. Musculo-Skeletal Limitation of movement [ + ] , Stiffness [ - ] , Joint swelling/redness [ - ] , Arthritis [ - ] , Muscle spasm [ - ] , Muscle weakness [ + ] Significance: Hemi paresis left side of the body Psychiatric Mood change [ - ] , Anxiety [ - ] , Suicidal thoughts/ attempts [ - ] Significance: none Laboratory Results Hematology Report

Normal Values Hemoglobin Hematocrit Red Blood Cells Count (RBC) White Blood Cells Count (WBC) Platelet Count Others: Differential Count Segmenters Lymphocytes Monocytes 0.50 0.70 0.20 0.40 0.02 0.07 M 140 170 g/L F 120 160 g/L M 0.42 0.52 F 0.37 0.47 M 4.5 5.5 x 1012/L F 4.0 5.2 1012/L 4 10 x 109/L 150 400 x 109/L

Results 96 0.28 2.73 15.5 395

0.93 0.05 0.02

Clinical Chemistry Report

Normal Values

Results

Creatinine B2

M 80 115 umol/L F (53-97) 0 41 u/L 65 80 g/L 35 50 g/L 15 35 g/L 3.6 6.5 mmol/L 0.4 1.86 mmol/L > 0.90 mmol/L < 3.4 mmol/L 0.18 0.84mmol/L

109.3

SGPT B2 Total CHON B2 Albumin B2 Globulin B2 Cholesterol B2 Triglycerides B2 HDL B2 LDL B2 VLDL B2

57.44 67.98 34.20 33.78 2.18 152 0.30 1.19 0.69

DRUG STUDY

NAME OF DRUG/ GENERIC NAME

INDICATION AND DOSAGE

ACTION

SIDE EFFECTS

RE

Name of Drug: Indication: Penicillins are usually Diarrhea, constipation, TAZOCIN Treatment of Systemic and bactericidal in action. nausea, headache, Common Name: or local bacterial They bind reversibly insomnia, rash, 2.25 g vial infections caused by to several enzymes erythema, pruritus, Piperacillin Na 2 g sensitive organisms; outside the bacterial vomiting, allergic Tazobactam Na 250 mg UTI, lower cytoplasmic reactions, urticaria 4.5 g vial respiratory tract, membrane. These and super infection Piperacillin Na 4 g intra-abdominal; skin enzymes, known as Tazobactam Na 500 mg and skin structure penicillin-binding infections; bacterial proteins (PBPs) are septicemia; involved in cell-wall polymicrobic synthesis and cell infections. division. Dosage: Interference with Adult & Children > 12yr. these processes 2.25-4.5 g/day 6-8 inhibits cell-wall hours or 12 hourly by synthesis, causing IM or IV infusion rapid destruction of (.20-30 min) the cell.

Mak

Teac

NAME OF DRUG/ GENERIC NAME Name of Drug: DUAVENT Common Name: Per 2.5 ml pulmoneb Ipatropium Br 500 mcg Salbutamol sulfate 2.5 mg

INDICATION AND DOSAGE

ACTION

SIDE EFFECTS

Indication: Bronchodilator Inhibits vagally mediated for treatment of reflexes by bronchospasm antagonizing associated with acetylcholine COPD, including chronic bronchitis, emphysema and asthma Dosage: 1-2 pulmoneb every 6-8 hours

CNS nervousness, P dizziness, headache Cardiovascular palpitations EENT blurred vision, epistaxis GI nausea, GI distress, dry mouth Respiratory cough, upper respiratory tract infection, bronchitis, bronchospasm Skin - rash

NAME OF DRUG/ GENERIC NAME

INDICATION AND DOSAGE

ACTION

SIDE EFFECTS

N R

Name of Drug: AEKNIL Common Name: Paracetamol

Indication: May produce analgesic Hematologic hemolytic T Pyrexia of unknown origin. effect by blocking anemia, neutropenia, Fever and pain pain impulses by leucopenia, associated with inhibiting thrombocytopenia common childhood prostaglandin or pain Hepatic liver damage disorders, tonsillitis, receptors sensitizers. (with toxic doses) upper respiratory tract May relieve fever by acting jaundice infections, post in hypothalamus heatimmunization regulating center Metabolic reactions, after hypoglycemia tonsillectomy and Skin rash, urticaria other conditions. Prevention of febrile convulsion. Headache, cold, sinusitis, muscle pain, arthritis and toothache. Dosage: 2-3ml depending on the severity of case, dose may be repeated 4 hourly. In severe of cases, dose may be administered by IV very slowly

Anatomy & Physiology Lobes of the Brain

The manifestations of stroke depend on which region and the extent of brain affected. The three main components of the brain: Cerebrum - the largest and most developmentally advanced part of the human brain. It is responsible for several higher functions, including higher intellectual function, speech, emotion, integration of sensory stimuli of all types, initiation of the final common pathways for movement, and fine control of movement. Cerebellum - second largest area, is responsible for maintaining balance and further control of movement and coordination. The brain stem is the final pathway between cerebral structures and the spinal cord. It is responsible for a variety of automatic functions, such as control of respiration, heart rate, and blood pressure, wake-fullness, arousal and attention. Cerebrum is divided into a right and a left hemisphere and is composed of pairs of frontal, parietal, temporal, and occipital lobes. The left hemisphere controls the majority of functions on the right side of the body, while the right hemisphere controls most of functions on the left side of the body The crossing of nerve fibers takes place in the brain stem. Thus, injury to the left cerebral hemisphere produces sensory and motor deficits on the right side, and vice versa.

Cerebellum and Brainstem A stroke involving the cerebellum may result in a lack of coordination, clumsiness, shaking, or other muscular difficulties. These are important to diagnose early, since swelling may cause brainstem compression or hydrocephalus Strokes in the brainstem are usually due to basilar occlusion, although in many cases the clinical syndrome may fit the criteria for a lacunar stroke. Brainstem strokes can be serious or even fatal. People who survive may be left with severe impairments or remain in a vegetative state.

Major Blood Vessels

Normal function of the brain's control centers is dependent upon adequate supply of oxygen and nutrients through a dense network of blood vessels.

Blood is supplied to the brain, face, and scalp via two major sets of vessels: the right and left common carotid arteries and the right and left vertebral arteries. The common carotid arteries have two divisions. The external carotid arteries supply the face and scalp with blood. The internal carotid arteries supply blood to the anterior three-fifths of cerebrum, except for parts of the temporal and occipital lobes.

The vertebrobasilar arteries supply the posterior two-fifths of the cerebrum, part of the cerebellum, and the brain stem. Any decrease in the flow of blood through one of the internal carotid arteries brings about some impairment in the function of the frontal lobes. This impairment may result in numbness, weakness, or paralysis on the side of the body opposite to the obstruction of the artery. Occlusion of one of the vertebral arteries can cause many serious consequences, ranging from blindness to paralysis. Circle of Willis At the base of the brain, the carotid and vertebrobasilar arteries form a circle of communicating arteries known as the circle of Willis. From this circle other arteries -- the anterior cerebral artery (ACA), the middle cerebral artery (MCA), the posterior cerebral artery (PCA) - arise and travel to all parts of the brain. Posterior Inferior Cerebellar Arteries (PICA), which branch from the vertebral arteries, are not shown. Because the carotid and vertebrobasilar arteries form a circle, if one of the main arteries is occluded, the distal smaller arteries that it supplies can receive blood from the other arteries (collateral circulation). Anterior Cerebral Artery The anterior cerebral artery extends upward and forward from the internal carotid artery. It supplies the frontal lobes, the parts of the brain that control logical thought, personality, and voluntary movement, especially the legs. Stroke in the anterior cerebral artery results in opposite leg weakness. If both anterior cerebral territories are affected, profound mental symptoms may result (akinetic mutism). Middle Cerebral Artery The middle cerebral artery is the largest branch of the internal carotid. The artery supplies a portion of the frontal lobe and the lateral surface of the

temporal and parietal lobes, including the primary motor and sensory areas of the face, throat, hand and arm and in the dominant hemisphere, the areas for speech. The middle cerebral artery is the artery most often occluded in stroke. Posterior Cerebral Artery The posterior cerebral arteries stem in most individuals from the basilar artery but sometimes originate from the ipsilateral internal carotid artery. The posterior arteries supply the temporal and occipital lobes of the left cerebral hemisphere and the right hemisphere. When infarction occurs in the territory of the posterior cerebral artery, it is usually secondary to embolism from lower segments of the vertebral basilar system or heart. Clinical symptoms associated with occlusion of the posterior cerebral artery, depend on the location of the occlusion and may include thalamic syndrome, thalamic perforate syndrome, Weber's syndrome, contralateral hemiplegia, hemianopsia and a variety of other symptoms, including color blindness, failure to see to-and-fro movements, verbal dyslexia, and hallucinations. The most common finding is occipital lobe infarction leading to an opposite visual field defect. Lenticulostriate Arteries Small, deep penetrating arteries known as the lenticulostriate arteries branch from the middle cerebral artery Occlusions of these vessels or penetrating branches of the circle of Willis or vertebral or basilar arteries are referred to as lacunar strokes. About 20% of all stokes are lacunar and have a high incidence in patients with chronic hypertension and in the elderly CT scanning shows signs of infarction in only approximately half of the most of the common form of lacunar stroke (pure motor stroke), but MRI has increased the yield

Pathophysiology 1.Disruption of blood to a part of the brain 2. Oxygenation of Neurons reduced 3. Anaerobic glycolysis 4. Sodium pump & neurotransmitter fail 5. Cerebral edema

6. Cerebral blood Vessel walls swell; Circulation is compromised and vasospasm combined with blood viscosity reduced cerebral perfusion 7. Outcomes of decreased cerebral perfusions: cerebral anoxia; cerebral infarction; contralateral deficits; permanent deficit Types of Stroke: (1) Ischemic Stroke Transient ischemic Stroke (TIA) - is a short-term stroke that lasts for less than 24 hours. The oxygen supply to the brain is restored quickly, and symptoms of the stroke disappear completely. A transient stroke needs prompt medical attention as it is a warning of serious risk of a major stroke Cerebral thrombosis occurs when a blood clot (thrombus) forms in an artery (blood vessel) supplying blood to the brain. Furred-up blood vessels with fatty patches of atheroma (arteriosclerosis) may make a thrombosis more likely. The clot interrupts the blood supply and brain cells are starved of oxygen. Cerebral embolism is a blood clot that forms somewhere in the body before travelling through the blood vessels and lodging in the brain. This causes the brain cells to become starved of oxygen. An irregular heartbeat or recent heart attack may make you prone to forming emboli.

(2) Hemorrhagic Stroke - occurs when a blood vessel bursts inside the brain and bleeds (hemorrhages). With a hemorrhage, extra damage is done to the brain tissue by the blood that seeps into it..

Signs and Symptoms of CVA Altered consciousness or unconsciousness stertorous breathing Unequal pupils ( larger pupil noted on same side as stroke) Paralysis of one side Perspiration Aphasia (abnormal or absent of speech) Blank stare Dysphagia Inability make decisions

Loss of memory Gait instability