Scientific Summit in School of

Medicine and School of Allied

Health Sciences
 GENERAL DATA

• 51 years old
• female
• Married
• Roman Catholic
• Filipino
• Mambaling, Cebu City
• Admitted for the 1st time in SWU-MC
 CHIEF COMPLAINT

Left sided weakness

HISTORY OF PRESENT ILLNESS
6 DAYS PRIOR
• 2 days PTA • No Consult done
• Metropolol 50 mg/tab BID
• (+) left-sided hemiparesis • Amlodipine 1 tab OD
• (+) difficulty standing • hemiparesis persisted
• (+) numbness
• (+) weakness of the left foot
• No syncope
• no loss of consciousness
noted
HISTORY OF PRESENT ILLNESS

• 1 day PTA

• symptoms persisted
• BP = 170/110 mmHg
 PAST MEDICAL HISTORY
• HPN:(+)
• Duration: 15 years
• Usual BP: 130/90 mmHg
• Max. BP: 210/120 mmHg
• DM: (-)
• Asthma: (-)
MAINTENANCE MEDICATIONS
• Clopidogrel
• Clonidine
• Godex
• Valsartan
PREVIOUS HOSPITALIZATION
/ SURGERY
• Appendectomy (1995, CHH);
• HTN (2004, CDU)
 SOCIAL HISTORY
• Food and Drug Allergy: none
• Alcohol: none
• Smoking: none
• Illicit drug use: none
PHYSICAL EXAMINATION
General Awake
Survey Coherent
Not in Respiratory Distress
Vital signs TEMP 35.6
RR 18 cpm
PR 61 bpm
O2 Sat 99% at room air
 PHYSICAL EXAMINATION
Skin Warm, good turgor
No rashes
HEENT Anicteric sclerae, Pink Palpebral
Conjunctiva
Neck No lymphadenopathy
Chest and Equal chest expansion
Lungs Clear breath sounds
 PHYSICAL EXAMINATION
Heart Distinct heart sounds
Regular rate and rhythm
No murmurs
Abdomen Flabby, Soft, Normoactive bowel sounds,
Non-tender, no masses
 PHYSICAL EXAMINATION
Extremities • No gross deformities seen, Strong
peripheral pulses, Capillary Refill
Time < 2secs.
 PHYSICAL EXAMINATION
Neurologic CNS: cerebral: oriented to time, place
and persons
 PHYSICAL EXAMINATION
I: DISTINGUISHED SMELL OF COFFEE
II & III: (+) PUPILS EQAULLY ROUND, REACTIVE TO
LIGHT AND ACCOMMODATION
III, IV & VI: EXTA OCCULAR MUSCLES INTACT
V & VII: (+) CORNEAL REFLEX
(+) FACIAL SYMMETRY
VIII: ALERTS TO SOUND
IX & X: (+) GAG REFLEX
XI: CAN SHRUG SHOULDER
XII: TONGUE MIDLINE
PHYSICAL EXAMINATION
Sensory: fair sharp and blunt sensations of the left foot

Motor: 5/5, 4/5, 4/5, 5/5

Cerebellar: left arm drifts, uncoordinated, poor heel to

shin test

Reflexes: 2+

Neurological Examination: GCS: E-4 M-5 V-6

 ADMITTING IMPRESSION

1. CVD Infarct Right Cerebellum (Hyperacute)

2. HACVD Not In Failure
 UPON ADMISSION
Urinalysis WBC 9.6
Color Dark Yellow Neutrophils 73.3 %
Transparency Cloudy Lymphocytes 16.1 %
Protein +1 Monocytes 6.9 %
Ketones Negative Hgb 11.5 mg/dL
Glucose Negative Hct 35.2 %
Red Blood Cell TNTC/hpf
Platelet 347 x 109 / L
Pus cells TNTC/hpf
Epithelial cells Few Na+ 143.2 mg/dL
Bacteria Moderate K+ 3.49 mg/dL
 UPON ADMISSION
Admit
• Diet: low salt, low fat
• Start venoclysis PNSS 40cc /hr
• LABS:
• Attach labs done as out patient
• CBG now
• 12L ECG
• FBS, Lipid Panel
• Transcranial Carotid Doppler
• 2D Echo with Doppler
• Input & Output q4hours in absolute figures, do not estimate
• Neuro vital signs q4hours
 UPON ADMISSION
• Refer for any unusualities
• BP: >180/100 mmHg
• Temp: >38 C, <34 C
• PR: >100 bpm, <60 bpm
• O2 Sat.: <92%
• RR: >25 cpm, <12 cpm
• Change in sensorium
 MEDICATIONS
1. Citicoline 1 g IVTT q6hours
2. Clopidogrel 75 mg/tab I tab PO PCBF
3. Atorvastatin 80 mg/tab I tab PO OD qHS
4. Pantoprazole 40 mg/tab I tab PO OD ACBF
5. Clonidine 75 mcg/tab I tab SL q6 PRN for SBP > 180/100
mmHg
6. Godex OS I tab PO BID
 COURSE IN THE WARDS
Hospital Day 1
Subjective Objective
BP: 150-160/100 mmHg
 COURSE IN THE WARDS
Hospital Day 1
Assessment Plan
1. CVD Infarct Right • Case and plans discussed
Cerebellum • Start with Nebivolol 5 mg/tab I tab
(Hyperacute)
PO OD
2. HACVD Not In
Failure
 COURSE IN THE WARDS
Hospital Day 2
Subjective Objective
• BP: 130/80-160/100 mmHg
• PR: 71 bpm
• RR: 20 cpm
• Temp: 36.5 C
• O2: 98%
 COURSE IN THE WARDS
Hospital Day 2
Assessment Plan
1. CVD Infarct Right • Mupiricin (Bactroban) Cream at
Cerebellum Right leg BID
(Hyperacute) • Case and plans discussed
2. HACVD Not In
Failure
 COURSE IN THE WARDS
Hospital Day 3
Subjective Objective
• BP: 130/80 mmHg
• PR: 69 bpm
• RR: 18 cpm
• Temp: 36.5 C
• O2: 96%
 COURSE IN THE WARDS
Hospital Day 3
Assessment Plan
1. CVD Infarct Right • Case and plans discussed
Cerebellum • Please facilitate for transcranial
(Hyperacute)
carotid doppler and 2d echo with
2. HACVD Not In doppler
Failure
 LABORATORIES

Test Result Unit Range

CBC
WBC 4.7 10^3/mm^3 4.4-11.0
RBC L 4.22 10^6/mm^3 4.50-5.10
PLT L 143 10^3/mm^3 150-450
 CAROTID DUPLEX SCAN
RIGHT: Kinked internal carotid artery
No overt plaques
No significantly elevated velocities

LEFT: Tortuous internal carotid artery

Thickened intima
No significantly elevated velocities

INTERPRETATION: No significant stenosis in either carotid system

Forward vertebral artery flow
 TRANSTEMPORAL WINDOW
TRANSTEMPORAL WINDOW
Right Left
Depth (cm) Velocity (cm/sec) P.I. Depth (cm) Velocity (cm/sec) P.I.
5 49-22-32 0.84 MCA No Signal
3 44-19-29 0.87 distal No Signal
6 37-19-25 0.76 proximal No Signal
6 -71-24-43 1.07 ACA No Signal

5 35-16-25 0.78 PCA

6 53-26-37 0.71 TICA

 TRANSORBITAL WINDOW
4 30-08-16 1.36 OPTH 4 35-11-19
1.24

ICA
7 1.00-46-67 0.81 siphon 7 60-28-42
0.76

TRANSFORAMINAL WINDOW
5 -42-16-24 1.13 VERT

BASILAR
Depth (cm) Velocity (cm/sec) P.I.
6 -37-15-25 0.90
COMMENT: Poor left temporal window
INTERPRETATION: No evidence of hemodynamically
significant stenosis in the insonated intracranial
arterial segment.
 SERUM SODIUM & POTASSIUM

Analyte Result Normal Range

Normal Range
Clinical Chemistry
Sodium 141 mmol/L [ 136-142 ]
Potassium 4.0 mmol/L [ 4.0-5.6 ]
\
LIPID PANEL

Test Result Unit Reference Range

FBS 99.17 mg/dL 70-100
Cholesterol 133.8 mg/dL 0-200
Triglycerides 89.7 mg/dL 25-148
HDL 44.95 mg/dL 35-88
LDL 70.9 mg/dL 0-150
VLDL 17.9 mg/dL 0-42
 CT SCAN: BRAIN PLAIN
IMPRESSION:
CHRONIC SMALL VESSEL ISCHEMIC CHANGES IN
BOTH FRONTOPARIETAL
PERIVENTRICULAR WHITE MATTER
ATHEROSCLEROTIC VESSEL DISEASE
SUGGEST COMPLETION SCAN
 CHEST XRAY
RADIOLOGIC FINDINGS

Examination reveals the lung fields are clear. The cardiac

silhouette is not enlarged.
The thoracic aorta and pulmonary vessels are unremarkable.
The diaphragm is sharp and distinct.
The trachea is in the midline. There are no bony abnormalities.

CONCLUSION: ESSENTIALLY NORMAL CHEST.

 CLINICAL CHEMISTRY

S. I. Units Conventional Units

Analyte Result Units Normal Range Result Units Normal Range
Creatinine 75.14 umol/L 50.39-98.12 0.85 mg/dL 0.57-1.11
SGPT (ALT) 37.50 U/L 0.00-55.00 37.50 U/L 0-55
 BLOOD GLUCOSE
Test Results Unit
HGT 91 mg/dl
 COURSE IN THE WARDS
Hospital Day 4
Subjective Objective
• BP: 140/90 mmHg
(-) fever • PR: 76 bpm
(-) DOB • RR: 20 cpm
(-) weakness of • Temp: 36.1 C
extremities • O2: 98% room air
• Input: 2,340cc
• Output: 1,280cc
• Fluid Balance: (+) 1,060cc
 COURSE IN THE WARDS
Hospital Day 4
Assessment Plan
1. CVD Infarct Right • May go home
Cerebellum • Follow-up at APs clinic after 1 week
(Hyperacute) CBC, Crea, SGPT, Na and K resolution.
2. HACVD Not In
Failure
 COURSE IN THE WARDS
Home Meds:
1. Clopidogrel 75 mg/tab 1 tab PO PCBF
2. Atorvastatin 80 mg/tab 1 tab PO OD qHS
3. Pantoprazole 40 mg/tab 1 tab PO OD ACBF
4. Godex OS I tab PO BID
5. Clonidine 75 mcg/tab 1 tab SL PRN for BP > 180/100
mmHg
6. Nebivolol 5 mg/tab 1 tab PO OD
7. Mupiricin (Bactroban) Cream at Right leg BID
FINAL DIAGNOSIS

1. CVD Infarct Right Cerebellum (Hyperacute)

2. HACVD Not In Failure
THANK YOU!