+ Admissions Conference Clerk Shari Atanacio

+ General Data R.M. 63 Male Right handed Married Roman Catholic Filipino Mechanic Tondo, Manila DOA: March 12, 2010

+ Chief Complaint Left sided weakness

+ History of Present Illness January 25, 2010 (11PM) – sudden loss of consciousness after urination – head hitting the banister – spontaneously regained consciousness after 30 seconds – event unrecalled by the patient – no headache, vomiting, blurring of vision, diplopia – no weakness, numbness – Ospital ng Maynila after 30 mins cranial xray: no fractures BP 160/100 PE was essentially unremarkable A> Hypertension Losartan 50mg/tab OD and Hydrochlorothiazide 12.5mg/tab OD Discharged improved and stable

+ History of Present Illness January 25 - Feb 2 nd week2010 apparently well able to do daily activities no complaints of headache, vomiting, weakness, numbness

+ History of Present Illness Feb 3 rd week episodes of headache throbbing, frontotemporal area, graded 5/10, occurring spontaneously, relieved by intake of Paracetamol

+ History of Present Illness Feb 4 th week – March 4, 2010 Apparently well Asymptomatic

+ History of Present Illness March 5, 2010 (4pm) – sudden lapses in remote and recent memory – unable to recall events, dates – able to recognize faces, remember the names of the people and things, and knows where he placed his things – answered to inquiries appropriately – L sided weakness difficulty in ambulating and gripping objects BP was at /90 self-medicated with ASA for 3 days – Change in behavior Easily irritable

+ Review of Systems (-) weight gain (-) weight loss (-) rashes, easy bruising (-) cough, dyspnea (-) ear discharge (-) hemoptysis, (-) night sweats (-) constipation, (-) diarrhea, nausea, vomiting (-) heat intolerance, palpitations (-) cyanosis, cold intolerance (-) dysuria, (-) flank pain (-) polyphagia (-) polydipsia, (-) polyuria, (-) joint pains

+ Past Medical History (+) Right forearm fracture (1980s) (+) HPN – (January 25, 2010) maintained on Losartan 50mg/tab OD and HCTZ 12.5mg/tab OD; UBP: /90 HBP: 150/90 (-) DM, stroke

+ Family Medical History (+) HPN - mother (-) DM, Thyroid disorder, stroke

+ Personal and Social History 12 smoking pack years Alcoholic beverage drinker from with consumption of 3 beers/day for 3 years Denies illicit drug use Mixed diet

+ Physical Examination on Admission Conscious, coherent, not in cardiorespiratory distress BP: 130/80 PR 76 bpm, regular RR 18 cpm T 36.5C BMI 26.5 Warm moist skin, no active dermatoses Pale palpebral conjunctivae, Anicteric Sclerae Moist buccal mucosa, no nasoaural discharge, epistaxis, tonsil not enlarged, non-hyperemic posterior pharyngeal wall Supple neck, no cervical lymph adenopathies, thyroid not enlarged, (-) carotid bruit

+ Physical Examination on Admission Symmetrical Chest Expansion, no retractions, clear breath sounds Adynamic Precordium, AB 5 h LICS MCL, no murmurs Flabby abdomen, normoactive bowel sounds, soft, non tender, no masses Pulses full and equal, no edema, no cyanosis

+ Neurological Exam Conscious, coherent, oriented to person, disoriented to time/date and place, cannot remember events but can recognize faces, remembers names of people and things, L hemineglect, follows command MMSE: 16/30 Pupils 3-4 mm OU, equally reactive to light, (+) Visual threat OU, (+) direct and consensual light reflex, no ptosis Funduscopy: (+) ROR, indistinct disc margins EOM full and equal V1V2V3 intact, can clench teeth No facial asymmetry, can raise both eyebrows, can close eyes tightly Gross hearing intact, no lateralization on Weber, AC>BC AU

+ Neurological Exam Uvula midline on phonation Can raise both shoulders against resistance Tongue midline on protrusion No muscle atrophy, fasciculations, spasticity, rigidity MMT 5/5 on RUE,RLE 4/5 LUE/LLE (-) Dysmetria and dysdiadokinesia DTR’s ++ (-) Babinski No sensory deficits No nuchal rigidity, Brudzinski, Kernig’s sign

+ Is there a neurologic deficit? Focal neurologic deficit Meningeal signs Increased intracranial pressure

+ Is there a neurologic problem? Focal Neurologic Deficit – Disturbance in intellectual function memory Emotions/behavior language seizure – Cranial nerve deficits – Weakness or paralysis of extremities – Incoordination, poor equilibrium – Reflex asymmetry, pathological reflexes – Sensory impairment

+ Where is the neurologic problem? Levelize Cerebrum Disturbed higher intellectual functions Behavioral changes Hemiparesis

+ Where is the neurologic problem? Localize Frontal lobe – hemiparesis Temporal lobe – behavior and memory changes Parietal lobe – constructional apraxia, hemineglect

+ Where is the neurologic problem? Lateralize Right Cerebrum (Frontal, Temporal and Parietal lobe)

+ What is the neurologic problem? congenital/developmental trauma Infection degenerative neoplasm vascular metabolic/Endocrine Intoxication Nutritional deficiency demyelinating immunologic

+ Assessment Intracranial Hemorrhage, probably Chronic Subdural Hematoma, R cerebrum

+ Plans CBC with plt PT, aPTT Serum Na, K, crea, BUN FBS, lipid profile UA Cranial MRI CXR 12L-ECG Mannitol 20% 75cc/IV q6 Lactulose 30cc ODHS, hold if BM >3x/day For evacuation of hematoma DiagnosticsTherapeutic