Calma * Capili * Dagang * Dayrit

FV FV 49/M 49/M Married, Roman Catholic, from Canlubang Laguna Married, Roman Catholic, from Canlubang Laguna Admitted to the PGH ER last April 2, 2010 Admitted to the PGH ER last April 2, 2010

Headache for 5 months Headache for 5 months

5 months PTA (+) occasional on and off headache VAS 2-3/1, B frontal area with radiation to the L side of the face and R periorbital area, (+) diplopia, decreased hearing on the L ear and tinnitus 3 months PTA Noted increase in severity of headache, moderate-severe, temporarily relieved by analgesics

1 month PTA (+) persistence of symptoms prompted consult with a private MD, cranial CT scan was done and revealed a sellar mass. Pt was referred to PGH 2 days PTA Pt seen at the PGH OPD, adviced cranial MRI with GAD. The next day, there was an ncrese in the severity of headache associated with dizziness and vomiting  pt brought to the PGH ER and hence present admission

(+) weight loss (25% in 5 months) (+) weight loss (25% in 5 months) (-) anorexia (-) anorexia (-) fever (-) fever (-) cough, colds (-) cough, colds (-) difficulty of breathing (-) difficulty of breathing (-) chest pain (-) chest pain (-) abdominal pain (-) abdominal pain (+) 3 P’s (+) 3 P’s (-) bowel complaints (-) bowel complaints (-) seizures (-) seizures (-) loss of consciousness (-) loss of consciousness (-) edema (-) edema

(+) HPN – since 2000, UBP 160/100, HBP 180/120, (-) maintenance medications (+) HPN – since 2000, UBP 160/100, HBP 180/120, (-) maintenance medications (+) DM – since 2003, (-) maintenance medications (+) DM – since 2003, (-) maintenance medications (-) PTB, BA, allergies, history or trauma, previous surgeries (-) PTB, BA, allergies, history or trauma, previous surgeries

(+) HPN – father (+) HPN – father (-) DM, PTB, BA, CA (-) DM, PTB, BA, CA

Truck driver, married with 6 children Truck driver, married with 6 children Non-smoker, occasional alcoholic beverage drinker, (-) illicit drug use Non-smoker, occasional alcoholic beverage drinker, (-) illicit drug use

BP 130/90 HR 90 RR 20 BP 130/90 HR 90 RR 20 PC, AS, (-) CLAD, (-) ANM PC, AS, (-) CLAD, (-) ANM ECE, CBS, (-)crackles/wheezes ECE, CBS, (-)crackles/wheezes (-) heaves/thrills, DHS, NRRR, AB 5 th ICS LAAL, (-) murmurs (-) heaves/thrills, DHS, NRRR, AB 5 th ICS LAAL, (-) murmurs Abdomen flat, NABS, soft, non-tender Abdomen flat, NABS, soft, non-tender FEP, PNB, (-) clubbing, (-) edema FEP, PNB, (-) clubbing, (-) edema

GCS 15, alert, awake, oriented to 3 spheres GCS 15, alert, awake, oriented to 3 spheres Cranial Nerves Cranial Nerves INot assessed IIPupils 3 mm EBRTL, VA: OD 20/40, OS , (-) visual field cuts III, IV, VI (+) LR palsy OS VV1: R 100% L 10%; V2: R 100% L 10%; V3: B 100% VIIShallow L NLF, (+) L central facial palsy VIIIWebber: Lateralized to the L, Rinne: AS: BC>AC IX, XGood gag XIGood shoulder shrug XIITongue midline

Motor Motor Good muscle bulk, (-) spasticity, (-) flaccidity 5/5 5/5 5/5 5/5 Sensory Sensory 100% 100% 100% 100%

DTRs DTRs   Cerbellars: (-) dysmetria, (-) dystiadochokinesia Cerbellars: (-) dysmetria, (-) dystiadochokinesia Meningeals: (-) nuchal rigidity, (-) Kernig’s, (-) Brudzinski Meningeals: (-) nuchal rigidity, (-) Kernig’s, (-) Brudzinski Autonomic Autonomic

(+) contrast enhancing tumor, ill defined involving sellar-supresellar, sphenoidal areas (+) contrast enhancing tumor, ill defined involving sellar-supresellar, sphenoidal areas

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(+) sellar-supresellar mass occupying the sphenoid sinus as well (+) sellar-supresellar mass occupying the sphenoid sinus as well (+) encasing B cavernous sinus with invasion of clivus (+) encasing B cavernous sinus with invasion of clivus Impression: Chordoma vs. Invasive Pituitary Adenoma Impression: Chordoma vs. Invasive Pituitary Adenoma

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CBC: 4/2: Hgb 103 Hct WBC 7.1 N L Plt 331 CBC: 4/2: Hgb 103 Hct WBC 7.1 N L Plt 331 PT/PTT: 4/2: 11.0/12.2/0.89/1.17; 32.6/37.3 PT/PTT: 4/2: 11.0/12.2/0.89/1.17; 32.6/37.3 4/5: FT4 8.4  (N pmol/L), TSH 0.8 (N mIU/L), Cortisol 25  (N nmol/L), PRL 3,041.9  (80-430mIU/L) 4/5: FT4 8.4  (N pmol/L), TSH 0.8 (N mIU/L), Cortisol 25  (N nmol/L), PRL 3,041.9  (80-430mIU/L)

4/24/34/64/104/124/164/19 Glucose 11.8  10.3 BUN Crea Na 127  126  119  115  132  K  Cl 88  90  85  72  Ca Mg0.68 Urine Na238 Urine K11.6 Urine Cl213

In the ER, pt managed primarily by NSS, co- managed by ORL, Ophtha, and Endo In the ER, pt managed primarily by NSS, co- managed by ORL, Ophtha, and Endo Pt GCS 15 while in the ER, no motor or sensory deficits. Pt GCS 15 while in the ER, no motor or sensory deficits. Pt on the following medications: Mannitol 75 cc IV Q8  Q6, Celecoxib 200 mg/cap Q12, Tramadol 50 mg/tab TID  Tramadol 50 mg IV Q8, Ketorolac drip (30 mg in 250cc D5W x 24h), Dexamethasone 5 mg/IV Q6 Pt on the following medications: Mannitol 75 cc IV Q8  Q6, Celecoxib 200 mg/cap Q12, Tramadol 50 mg/tab TID  Tramadol 50 mg IV Q8, Ketorolac drip (30 mg in 250cc D5W x 24h), Dexamethasone 5 mg/IV Q6

ORL: A> hearing loss etiology to be determined. Plan for PTA-ST and for transsphenoidal biopsy/GA once admitted ORL: A> hearing loss etiology to be determined. Plan for PTA-ST and for transsphenoidal biopsy/GA once admitted Ophtha: A> LR palsy probably secondary to malignancy. Refraction done. Plan for visual perimetry. Ophtha: A> LR palsy probably secondary to malignancy. Refraction done. Plan for visual perimetry.

Endo: A> Consider secondary hypogonadism, secondary hypothyroidism, secondary hypoadrenalism secondary to suprasellar mass with mass effect. Hyperglycemia probably secondary to DM vs. steroid induced vs. combination. Hyponatremia secondary to SIADH due to tumor, secondary hypothyroidism, secondary to AI, secondary to mannitol use, orsecondary to hyperglycemia. Pt started on Levothyroxine 100 mcg/tab 30 min before breakfast, HN SQ pre-melas, HR SQ pre-meals, defer for CBG Consider secondary hypogonadism, secondary hypothyroidism, secondary hypoadrenalism secondary to suprasellar mass with mass effect. Hyperglycemia probably secondary to DM vs. steroid induced vs. combination. Hyponatremia secondary to SIADH due to tumor, secondary hypothyroidism, secondary to AI, secondary to mannitol use, orsecondary to hyperglycemia. Pt started on Levothyroxine 100 mcg/tab 30 min before breakfast, HN SQ pre-melas, HR SQ pre-meals, defer for CBG < 70mg/dL.