GENERAL DATA  M.R.  34 years old/Female/Single  Right handed  Place of Birth: Oriental Mindoro  Roman Catholic  Fish vendor  Quezon City  Date of Admission: January 29, 2010  Informant: Patient  Reliability: Good

CHIEF COMPLAINT  Headache

HISTORY OF PRESENT ILLNESS  Headache located on the left temporal area pressing in character graded as 5/10 No associated vomiting, diplopia, blurring of vision, or weakness Patient could still perform usual activities  Consult was done in a private clinic in Olongapo Tramadol was prescribed CBC and Urinalysis were done Nov, 2009

HISTORY OF PRESENT ILLNESS  Increase in severity of headache same location graded as 8/10 patient still does her usual activities no difficulty in ambulation  Consult done in another hospital in Olongapo December 2009

HISTORY OF PRESENT ILLNESS  CT scan was requested Faint enhancing lesions in the left frontal and left thalamus with areas of low attenuation Findings may relate to infectious/inflammatory or neoplastic process December 2009

HISTORY OF PRESENT ILLNESS  Prescribed medications Pregabalin (Lyrica) 150mg/cap, OD for 7days Meloxicam(Mobic)15mg, OD December 2009

HISTORY OF PRESENT ILLNESS  I ncrease in severity of headache, which would now affect her usual activities January, 2010

HISTORY OF PRESENT ILLNESS January 22, 2010  Headache associated with Diplopia & vomiting  Consult done in Zambales and MRI was requested. Patient went to PGH for the procedure however, due to conflict in schedule, opted to transfer to UST

REVIEW OF SYSTEMS  Notable weight loss, loss of appetite  No fever  No rash, no pruritus  No visual disturbances, no eye, nose, or ear discharge  No cough, no difficulty of breathing  No chest pain, no easy fatigability, no orthopnea, no palpitations

REVIEW OF SYSTEMS  No urgency, no hesitancy, no frequency, no gross hematuria  No diarrhea, no constipation  No heat or cold intolerance, no polydipsia, no polyuria, no polyphagia  No easy bruisability, no bleeding, no cyanosis, no edema  No hallucinations, no personality changes

PAST MEDICAL HISTORY  (+) Pneumonia: treated (outpatient) with unrecalled antibiotics  (-)Thyroid diseases  (-)DM  (-)HPN  (-)Blood dyscrasia  (-)Malignancy  (-) asthma  (-)allergy

FAMILY MEDICAL HISTORY  (-) Cancer  (-) Hypertension  (-) Renal disease  (-) Cardiovascular disease  (-) Tuberculosis  (-) Hematologic disease  (-) No endocrine disease  (-) asthma  (-) Allergy

Gynecologic History  G3P3( )  Last Menstrual Period: Jan 21-24, 2010  Past Menstrual Period: Nov 21-24, 2009  Oral Contraceptive pill user for 13 years  First sexual contact: 17years old  One sexual partner

MENSTRUAL PERIOD  Menarche: 12 years old  Interval: every days  Duration: 3-4 days  Amount: 1-2 pads per day  Symptoms: (+)Dysmenorrhea

PERSONAL AND SOCIAL HISTORY  Mixed diet  Non-smoker  Non-alcoholic beverage drinker  Denies illicit drug use

Physical Examination  Conscious, coherent, ambulatory, not in cardiorespiratory distress  BP: 130/80 PR: 82 bpm, reg RR: 20 cpm, reg T: 37.6 C  Ht: 155cm wt: 60kg BMI: 25  Warm, moist skin, (+)Verruca plantaris, right foot; no pallor, no jaundice  Pink palpebral conjunctivae, anicteric sclera, pupils 2- 3mm equally reactive to light, midline nasal septum, Turbinates not congested, no nasoaural discharge,, no masses, moist buccal mucosa, nonhyperemic posterior pharyngeal wall, tonsils not enlarged

Physical Examination  Supple neck, thyroid not enlarged, no palpable cervical lymph nodes, no anterior neck mass, no carotid bruit  Breast: symmetrical, no abnormal discharge, no skin dimpling, no palpable axillary lymph nodes  Symmetrical chest expansion, no retractions, Clear and equal breath sounds  Adynamic precordium, AB at 5th LICS along MCL, no murmurs  Flat abdomen, normoactive bowel sounds, soft, nontender, no mass  Pulses full and equal, no cyanosis, no edema

NEUROLOGIC EXAMINATION Conscious, coherent, oriented to time, to place, and to person MMSE: 28/30 Olfaction intact in both nostrils Pupils 2-3mm equally reactive to light, (+)ROR, (-)papillededma,(-)hemorrhages, (+)Direct & consensual pupillary reflex, no visual field cuts Extraoculomotor muscles full and equal, (+) conjugate gaze V1V2V3 intact sensory

NEUROLOGIC EXAMINATION can raise eyebrows, can frown, can smile, can puff cheeks, intact gross hearing, no lateralization on Weber ’ s, AC> BC Rinne’s can shrug shoulders equally can turn head from side-to-side Tongue midline on protrusion, uvula midline on phonation,

Can do finger-to-nose test and alternating pronation-supination test with ease (-) Romberg’s sign Able tandem walk NEUROLOGIC EXAMINATION

MOTOR 4/5 5/5 4/55/5 4/5 5/5 No muscle atrophy, no fasciculations, no spasticity, no rigidity (+)pronator drift, right

DEEP TENDON REFLEXES ++

No Babinski, No Nuchal rigidity No Kernig’s, no brudzinski’s NEUROLOGIC EXAMINATION

ASSESSMENT Intracranial Mass Lesion probably neoplastic (1) Primary (2) Metastatic

PLANS Serum Sodium, Potassium, CBC, BUN, Creatinine, Chest X ray MRI Mammography CT scan of whole abdomen Ultrasound of the whole abdomen Referral to Neurosurgery Referral to Gynecology Paps Smear Transvaginal Ultrasound

NEUROLOGIC DIAGNOSIS I.Identify presence of neurologic problem II.Determine the location of the neurologic problem (anatomy) III.Identify the lesion (pathophysiology) Lowenstein, et al. Approach to the Patient with Neurologic Disease. Harrison’s Principles of Internal Medicine, 17 th edition. 2008

NEUROLOGIC DIAGNOSIS I.Identify presence of neurologic problem Lowenstein, et al. Approach to the Patient with Neurologic Disease. Harrison’s Principles of Internal Medicine, 17 th edition ?Focal Neurologic Deficits ?Increased Intracranial Pressure ?Meningeal Irritation NEUROLOGIC DIAGNOSIS Headache Diplopia Vomiting

NEUROLOGIC DIAGNOSIS II.Determine the location of the neurologic problem (anatomy) Adams and Victor’s : Principles of Neurology, 8 th ed NEUROLOGIC DIAGNOSIS Levelize Localize Lateralize (+) Diplopia Level of the pons

NEUROLOGIC DIAGNOSIS III.Identify the lesion (pathophysiology) Lowenstein, et al. Approach to the Patient with Neurologic Disease. Harrison’s Principles of Internal Medicine, 17 th edition Temporal Profile Other useful information NEUROLOGIC DIAGNOSIS

III.Identify the lesion (pathophysiology) Lowenstein, et al. Approach to the Patient with Neurologic Disease. Harrison’s Principles of Internal Medicine, 17 th edition Temporal Profile Other useful information NEUROLOGIC DIAGNOSIS Chronic Headache Gradual evolution over months (+) diplopia, (+) vomiting Slowly progressing without remissions Consider: Mass lesions (neoplasm, abscess, hematoma)

HISTORY OF PRESENT ILLNESS January 22, 2010  MRI findings Multiple rim enhancing lesions in the gray matter junction in both fronto- parietal region and left basal ganglia with varying amounts of surrounding vasogenic edema and some hemorrhagic foci