1. Case Discussion

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

3. 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 (-) loss of vision (-) consults

4. 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.

5. ROS (-) fever (-) weight loss (+) diplopia (+) N&V (-) DOB (-) palpitations (-) urinary and bowel movement changes (-) sensory and motor deficits

6. 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

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

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

9. 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

10. 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 midline Sensory : 100% on all extremities Motor: No lateralized weakness DTRs: 2+ on all extremities (-) cerebellar sign (+) babinski, B

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

12. Diagnostics Baseline labs – CBC – BUN/Crea – Electrolytes – PT/PTT – Typing – UA – ECG CT scan 4V angiogram

13. Results CBCWBCHgbHctpltneutlymphmoneos 11/2615.59152.466366.781.121.083.013 12/420.92126.372335.893.057.045.004 HDLTrigluBUNCreacholLDLNaKCl 11/26.88 (34).67(5 9) 5.753.98664.243.1 (119) 1373.5 11/2964135 L3.7 12/4591393.7108L

14. Results PT (11/27) : protime – 12. 6 (11-14sec), % act – 90%, INR 1.06, Control 14.5 (11.5-15.5) 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

15. CT scan (+) SAH centered in the area of the L Sylvian fissure (+) suspicious focus of enhancement in the area of the L MCA bifurcation (+) slight dilatation of entire ventricular system IMP: SAH on the L Sylvian fissure Saccular aneurysm in the L MCA bifurcation

16. 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

17. 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.

18. 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 tabs @ 8am with some sips of water Advised to prepare 2 pack RBC

19. Procedure 12/4: s/p L pterional craniotomy, clipping of aneurysm – OR length: 5 hrs – EBL: 250cc – UO 1.4L – intraop VS BP 120/80 -170/100 – total IVF:3L

20. 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

21. 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, B (-) clonus

22. Post op meds Cloxacillin 1gm IV q6 Gentamycin 240 mg Oral meds: – Famotidine 20mg/tab 1 tab q12 – citicholine 500mg/cap 2 caps q12 – Nimodipine30mg/tab 2 tabs q4 – lactulose 30 cc @HS – simvastatin40mg/tab @HS – leviteracetam 500mg/tab1 tab OD – Celecoxib 200mg/cap 1 cap BID – Salbutamol neb prn

23. 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