Case Discussion

General Data Lee, Rosalinda 41/F, married from Malate Manila CC: headache Date admitted: 11/25/09

HPI Five days PTA, patient was suddenly awakened by onset of L sided headache, described as very severe (VAS 8/10). This was accompanied by rolling of eyeballs, urinary incontinence and loss of consciousness. Patient felt asleep then but upon waking up (+) nausea and vomiting(-) sensory and motor deficits. (-) consults

HPI 2 days PTA, patient still had persistent headache VAS 4-8/10. She consulted a private doctor and was diagnosed with migraine and HPN and was given with unrecalled medication. However, there was no relief and thus decided to consult a neurologist.

ROS (-) fever (-) weight loss (+) BOV, OU (+) N&V (-) DOB (-) palpitations (-) urinary and bowel movement changes (-) sensory and motor deficits

PMHx (+) HPN - diagnosed case (1997), previously maintained on Aspilet and Neoblock but had stopped 3 months ago (-) DM/TB/liver, kidney disease (+) asthma – last attack Nov 20, 2009, on prn salbutamol

FMHx (+) HPN – mother (+) CVD infarct – mother’s side (-) DM/asthma/TB/cancer

P&SHx Patient runs a small eatery near their house in their area, (-) vices

Physical Examination 140/808620afeb AS PC (-) CLAD (-) TPC ECE CBS (-) rales, wheezes AP DHS NRRR (-) murmurs Soft flat abdomen, (-) masses, (-) tenderness PNB, Full and Equal pulses

Neurologic Exam GCS 15 (E4V5M6) Awake, oriented, follows commands CNs – I: able to smell and identify – II: pupils 3mm EBRTL – III, IV, VI : (+) L lateral palsy – V: B brisk corneals – VII: (-) FA – VIII: intact gross hearing – IX, X: good gag – XI: good shoulder shrug – XII: tongue modline Sensory : 100% on all extremities Motor: No lateralized weakness DTRs: 2+ on all extremities (-) cerebellar sign (+) nuchal catch

Primary Working Impression SAH 2 to ruptured LMCA Aneurysm HPN BANIAE Plan: pterional clipping of aneurysm (Pua, 12/4/09)

Diagnostics Baseline labs – CBC – BUN/Crea – Electrolytes – PT/PTT – Typing – UA – ECG 4V angigram

Results CBCWBCHgbHctpltneutlymphmoneos 11/ / HDLTrigluBUNCreacholLDLNaKCl 11/26.88 (34).67(5 9) (119) / L3.7 12/ L

Results PT (11/27) : protime – (11-14sec), % act – 90%, INR 1.06, Control 14.5 ( ) B+ UA (11/27) light yellow, slightly hazy, RBC +1, (-) bil, urobil +1, ketones +2, (-) LB/NITRITE/GLU, ph 6.5 SG 1.025, +1 leuc ECG: RSR, NA, NSSTTWC

Results Cerebral angiogram (12/1/09) – IMP: saccular aneurysm with narrow neck, directed anteriorly, LMCA bifurcation site. Presence of mild spasm as described – Slight hypoplasia, A1 segment, R anterior cerebral artery. Patent anterior communicating artery. – Patent R PCA

Course in the ward Patient was comanaged by IR for 4VA, neurology and cardiology for HPN Prior to contemplated procedure, patient is awake, (-) headache/nape pain/seizure/new deficits.

Preop Meds: – cloxacillin 1gm IV ANST (-) – Gentamicin 240 mg/IV 1 hr PTOR – Famotidine 20mg/IV – Leviteracetam500mg/tab at 8am despite NPO – Amlodipine 30mg/tab 2 8am with some sips of water Advised to prepare 2 pack RBC

Procedure 12/4: s/p L pterional craniotomy, clipping of aneurysm – OR length: 5 hrs – EBL: 250cc – UO 1.4L – intraop VS BP 120/ /100 – total IVF:3L

Post op P.E Awake, conversant, follows commands comfortable Physical Examination VS: – AS PC (-) CLAD (-) TPC – ECE CBS (-) rales, wheezes – AP DHS NRRR (-) murmurs – Soft flat abdomen, (-) masses, (-) tenderness – PNB, Full and Equal pulses

Neuro Exam Awake, coherent, conversant, oriented to 3 spheres, follows commands CNs: – I: able to smell and identify – II: pupils 3mm EBRTL – III, IV, VI : full EOMs – V: B brisk corneals – VII: (-) FA – VIII: intact gross hearing – IX, X: good gag – XI: good shoulder shrug – XII: tongue modline Sensory : 100% on all extremities Motor: No lateralized weakness 5/5 on all extremities DTRs: 2+ on all extremities (-) cerebellar signs (-) nuchal rigidity ( -) babinski Bil babinski (-) clonus

Post op meds Cloxacillin 1gm IV q6 Gentamycin 240 mg Oral meds: – Famotidine – citicholine – Nimodipine – lactulose – simvastatin – leviteracetam – Celecoxib – salbutamol

Note: dosages of the drugs to follow, not written in chart kung may babinski sya preop, still have to check nuchal rigidity post op. Pls also see the patient, nakasulat sa chart na no facial asymmetry, muka naman may ptosis ung patient at may shallow nasolabial fold sa L. CT scan