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63/F Married Filipino Patul, Santiago City Isabela Chief Complaint: Facial Asymmetry

This medical record is for a 63-year-old Filipino woman who presented with sudden onset right facial asymmetry, dizziness, nausea, and slurred speech. She has a history of hypertension. Physical examination revealed flattened right nasolabial fold and blood pressure of 160/100. CT scan showed cerebrovascular hemorrhage in the right middle cerebral artery territory. She was given IV fluids and medications to manage her conditions and referred to neurology service.

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Radley Jed Pelagio
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95 views14 pages

63/F Married Filipino Patul, Santiago City Isabela Chief Complaint: Facial Asymmetry

This medical record is for a 63-year-old Filipino woman who presented with sudden onset right facial asymmetry, dizziness, nausea, and slurred speech. She has a history of hypertension. Physical examination revealed flattened right nasolabial fold and blood pressure of 160/100. CT scan showed cerebrovascular hemorrhage in the right middle cerebral artery territory. She was given IV fluids and medications to manage her conditions and referred to neurology service.

Uploaded by

Radley Jed Pelagio
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PPTX, PDF, TXT or read online on Scribd
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C. E.

63/F
MARRIED
FILIPINO
PATUL, SANTIAGO CITY
ISABELA

CHIEF COMPLAINT:
FACIAL ASYMMETRY
HISTORY OF
PRESENT ILLNESS

PRESENTED WITH SUDDEN ONSET OF RIGHT


FACIAL ASYMMETRY WITH ASSOCIATED
2 HOURS DIZZINESS, NAUSEA AND SLURRED SPEECH.

PTA
PATIENT WAS IMMEDIATELY BROUGHT TO OUR
INSTITUTION THEN ADMITTED.
Integumentary: (-)pruritus
REVIEW OF Nervous: (-)seizures, (-)loss of consciousness, (-)headache,
SYSTEMS Cardiologic: (- )chest pain, (-) palpitations, (-)orthopnea, (-)easy
fatigability,
(-) paroxysmal nocturnal dyspnea

Pulmonary: (-) cough, (-) dyspnea, (-) shortness of breath

Gastrointestinal: (-)dysphagia , (-)LBM, (-)constipation, (-) vomiting,


(-) epigastric pain

Genitourinary: (-)oliguria,(-)hematuria, (-)dysuria

Hematologic: (-)bleeding tendencies,(-)easy bruisability

Endocrine: (-) body weakness, (-)weight loss, (-)night sweats


 PAST MEDICAL HISTORY
+ HYPERTENSION 10-15 YEARS ON LOSARTAN 50MG/TAB OD
NO DM, NO CARDIAC DISEASE,
NO BA, NO PTB TREATMENT, NO ALLERGIES

 FAMILY MEDICAL HISTORY


UNREMARKABLE

 PERSONAL SOCIAL HISTORY


BRGY KAGAWAD
NON SMOKER
OCCASSIONAL ALCOHOL BEVERAGE DRINKER
General survey: awake , conscious, coherent, not in
cardiorespiratory distress,
Skin: no pallor, no jaundice, no rashes, no lesions
PHYSICAL HEENT: anicteric sclerae, pink conjunctivae, no neck vein
EXAMINATION engorgement, no neck mass, no CLAD, no carotid bruit
Chest/Lungs: symmetrical chest expansion, no
retractions, clear breath sounds
BP- 160/100
Heart: adynamic precordium, normal rate, regular
CR- 85 rhythm, no murmur
RR-20 Abdomen: flat, normoactive bowel sounds , no
TEMP-36.5 organomegaly, soft, no palpable mass, non-tender
O2 SAT- 99% abdomen
Extremities: no gross deformities, no edema, no
cyanosis, +pulses
MSE: AWAKE, CONSCIOUS, COHERENT, ORIENTED TO 3 SPHERES,
NO TICS, NO MANNERISM, CLEAR SPEECH

MOTOR: 5/5 RIGHT UPPER AND LOWER EXTREMITY

Neurologic 5/5 LEFT UPPER AND LOWER EXTREMITY

Exam
SENSORY: 100%

DTRS: +2 RIGHT EXTREMITIES , +2 LEFT EXTREMITIES


CRANIAL CN 1: ABLE TO SMELL PERFUME
NERVES CN II: 3-4 MM PERLA
CN III,IV,VI: INTACT EOMS, CAN COUNT CF
V: + FACIAL GRIMACE, INTACT FACE SENSATION
VII: FLATTENING OF RIGHT NASOLABIAL
VIII: ABLE TO HEAR NO NUCHAL
IX/X: INTACT GAG REFLEX RIGIDITY
XI: CAN MOVE HEAD SIDE TO SIDE, SHRUG NEGATIVE
SHOULDERS BRUDZINSKI
NEGATIVE KERNIGS
XII: MIDLINE TONGUE
NEGATIVE BABINSKI
 63F
 KNOWN HYPERTENSIVE
 SUDDEN ONSET OF FACIAL ASYMMETRY
SALIENT  SLURRED SPEECH, NAUSEA, DIZZINESS
FEATURES  FLATTENED RIGHT NASOLABIAL
 BP 160/100
IMPRESSION:
CEREBROVASCULAR
HEMORRHAGE, RIGHT MCA
TERRITORY, ICH 0
HYPERTENSION STAGE II
UNCONTROLLED
COVID SUSPECT MILD
CXR
ECG

HR: 75-80 BPM


REGULAR RHYTHYM
NORMAL AXIS

SINUS RHYTHYM,
NON SPECIFIC ST T WAVE
CHANGES IN LEAD III,
AVF
CRANIAL
CT SCAN
HGB HCT WBC PMN LYM MONO PLT
11.2 35 9.13 62.1 30.8 5.3 305

HGT CREA BUN NA K EGFR BCR


LABORATORY 124 118.7 20.1 135.5 4.25 42.1 15
RESULTS
CA AST ALT LDH
1.16 22 26 175
MANAGEMENT IVF: PNSS 1L X 100cc/hour x 8 hours

 MANNITOL 200cc/iv bolus then 150cc/iv q4


 ATORVASTATIN 40MG/TAB ODHS
 LOSARTAN 50 MG/TAB OD
 AMLODIPINE 10 MG/TAB OD
 TRANEXAMIC ACID 1G + 100 CC PNSS X 30 MINUTES THEN
1G + 250CC PNSS X 8 HOURS
 LACTULOSE 30CC ODHS
 PARACETAMOL 300MG/IV Q4 PRN

 REFERRED TO NEURO SERVICE

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