1. + Admissions Conference Clerk Shari Atanacio

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

3. + Chief Complaint Left sided weakness

4. + 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

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

6. + History of Present Illness Feb 3 rd week 2010 2 episodes of headache throbbing, frontotemporal area, graded 5/10, occurring spontaneously, relieved by intake of Paracetamol

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

8. + 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 130-140/90 self-medicated with ASA for 3 days – Change in behavior Easily irritable

9. + 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

10. + Past Medical History (+) Right forearm fracture (1980s) (+) HPN – (January 25, 2010) maintained on Losartan 50mg/tab OD and HCTZ 12.5mg/tab OD; UBP: 130-140/90 HBP: 150/90 (-) DM, stroke

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

12. + Personal and Social History 12 smoking pack years Alcoholic beverage drinker from 1972-75 with consumption of 3 beers/day for 3 years Denies illicit drug use Mixed diet

13. + 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

14. + 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

15. + 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

16. + 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

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

18. + 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

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

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

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

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

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

24. + 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