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Description : Case of CVD

Tags : stroke, cvd

Published on : Dec 03, 2020 | Views : 1364 | Downloads : 0

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CASE PRESENTATION
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To be able to give an initial impression of the case To explain the signs and symptoms of the patient in relation to the clinical impression To be able to discuss the differential diagnoses and to rule out diseases which do not explain manifestations of the patient. OBJECTIVES:
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To answer the identified issues and problems with regards to the patient’s condition. To identify appropriate laboratory tests and management OBJECTIVES:
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Name: E.L. Age: 69 year old Sex: Male Address: Tugbungan, Zamboanga City Civil Status: Married Occupation: Unemployed Religion: Roman Catholic Nationality: Filipino Educ. attainment: High School Level Personal Data
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Loss of consciousness Chief Complaint
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Few hours PTA Nape pain Took Nifedipine (Adalat) tablet 5 mg - no relief. Sudden onset of dizziness with loss of consciousness (30minutes) No chest pain and no shortness of breath Left sided weakness History of Present Illness
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Few hours PTA Brought to a private hospital where he regained consciousness. Intravenous lines established with IV fluids; Given unrecalled medications. Subsequently brought to Zamboanga City Medical Center. History of Present Illness
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Course in the Ward On the 3rd hospital day, patient had productive cough and fever. History of Present Illness
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Medical Illness: Diagnosed with hypertension in the year 1983, Maintenance medication: Nifedipine (Adalat) 5mg but is not compliant Previous Hospitalization: None Surgical: No prior surgery Psychiatric: No history of depression Allergies: No known allergies Past Medical History
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Hypertension on both sides, including his siblings Both parents are deceased (both had history of stroke) (-) DM, Asthma, Cancer Family History
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Lives with wife and children. Diet: rice, vegetables and dried fish. No regular exercise. Known smoker of 50pack years and had stopped a year ago Occasional alcoholic drinker Personal and Social History
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General: (-) weight loss ( -) easy fatigability, (+) body weakness Skin: (-) rash, (-) lumps or nodules, (-) sores (-) pruritus, (-) clubbing (-) diaphoresis Review of System
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Head: (-) lightheadedness (+) dizziness, (+) occasional headache Eyes: (+) blurring of vision OD, with no prior check-up, (+) use of reading-glasses, (-) double vision (-) pain (-) redness, (-) excessive tearing of the eyes Ears: (-) pain (+) decreased in hearing on both ears, (-) tinnitus, (-) discharges Nose: (-) colds; (-) nosebleeds Throat: (-) upper and lower teeth (+) dry mouth (-) bleeding gums, (-) sore tongue (-) hoarseness Review of System
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Neck: (+) nape pain, (-) stiffness, (-) swelling, (-) mass/lumps Respiratory: (-) dyspnea, (+) productive cough, (-) PND, (-) hemoptysis Cardio: (-) palpitations (-) chest pain, (+) orthopnea: uses 2 pillows at night Review of System
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Gastro: (+) anorexia, (+) abdominal pain, (-) nausea, (-) constipation, (-) distention Genito-urinary: (-) frequency of urination, polyuria (-) dysuria, (-) hematuria, (-) foul-smelling discharge, (+) nocturia (-) frothy urine Peripheral: (-) cramps (-) varicose veins (-) intermittent claudication (- ) paresthesia Review of System
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Musculoskeletal: (+) joint pain on both knees (-) limitation of range of motion (-) stiffness Extremities: (+) Left sided weakness Neurologic: (-) seizures (-) tremors or other involuntary movement Review of System
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Endocrine: (-) excessive sweating , (-) heat or cold intolerance (-) polydipsia (-) polyphagia Hematologic: (-) easy bruising or bleeding, (-) history of bleeding Psychiatric: (-) Nervousness, (-) depression, (-) tension Review of System
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GENERAL APPEARANCE: not in respiratory distress, conscious but drowsy, uncooperative. With IVF via peripheral line Physical Examination
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VITAL SIGNS: Blood Pressure : 200/100mmHg (lying, left arm) Pulse rate: 80 bpm Respiratory Rate: 18 cpm Temperature: 36.6 °C Physical Examination
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SKIN/HAIR/ NAILS: Skin cold to touch (-) pallor, (-) cyanosis (-) rashes (-) clubbing Physical Examination
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Head: Hair distribution is equal, black and of average texture, normocephalic, (-) lesions Eyes: Anicteric sclera, pink palpebral conjunctivae, (+) opacity OU Ears: normal pinna; (-) discharges/bleeding, poor acuity to whisphered voice Nose/Sinuses: symmetrical (-) flaring of alae nasi, septum at midline (-) discharges (-) bleeding (+) Presence of NGT Mouth/Throat: Pink, moist oral mucosa, tongue deviated to right side (-) ulceration (-) lesions (-) tonsilopharyngeal congestion Physical Examination
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NECK Inspection: Symmetrical, supple, midline trachea, (-) visible neck mass, JVP -7cm Palpation: (-) Cervical lymphadenopathy, (-)tenderness, (-)thyroid enlargement Auscultation: (-) carotid bruit Physical Examination
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THORAX & LUNGS Inspection: symmetrical chest expansion, (-) scar (-) lesion, (-) use of accessory muscles, (-) visible retractions, (-) cyanosis Palpation: (-) tenderness (-) mass Percussion: (+) Resonant both lung fields Auscultation: (+) coarse crackles on both lung field (-) wheezing, bronchophony, egophony or whispered pectoriloquy not assessed Physical Examination
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CARDIOVASCULAR Inspection: adynamic precordium, (-) scar Palpation: (-) heaves, (-) thrill Auscultation: Normal rate and regular rhythm, PMI heard at 7th intercostal space, anterior axillary line (-) murmur, (-) bruit. S2 louder than S1 at apex Physical Examination
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ABDOMEN Inspection: (-) visible organomegaly, (-) visible pulsation, distended veins (-) lesion Auscultation: normoactive bowel sounds @ 13/min (-) bruit Palpation: soft, non tender (-) mass, (-) hepatosplenomegaly , (-) fluid wave, (-) shifting dullness Percussion: (-) dullness on all four quadrants Physical Examination
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GENITALIA: Not assessed , (+) presence of urinary cathether RECTAL: Not assessed Physical Examination
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EXTREMITIES: cold skin, symmetrical (-) atrophy (-) clubbing (-) cyanosis (-) edema (+) pale nail bed (+) left sided hemiplegia Physical Examination
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PERIPHERAL VASCULAR (+) both bounding but peripheral pulse decrease at left foot, CRT < 2seconds Physical Examination
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MUSCULOSKELETAL: (-) deformity, limited range of motion on right side, flaccid paralysis on left side (-) joint pain (-) stiffness Physical Examination
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MENTAL STATUS Drowsy, uncooperative but sometimes cooperative, incoherent, GCS – 12 (E3V4M5) NEUROLOGIC Exam
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CRANIAL NERVE EXAMINATION: I, II- Smell – not assessed/ done III,IV,VI – (+) Doll’s eye movement V – (+) Corneal reflex VII – (+) left facial palsy VIII – not assessed IX,X – not assessed XI - not assessed XII – (+) deviation of tongue to right side NEUROLOGIC Exam
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MOTOR SYSTEM No involuntary movement movements such as tremors, tics or fasciculation, No muscular atrophy Muscle strength: 3/5 on both right upper and lower extremities; 0/5 on both left upper and lower extremities NEUROLOGIC Exam
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SENSORY SYSTEM: Not assessed Babinski Reflex: (-) on right foot, (+) on left foot Brudzinski’s sign (-) Kernig’s Sign (-) NEUROLOGIC Exam
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CVD probably Bleed probably Basal Ganglia; Hypertension Stage 2 (JNC7); Hospital Acquired Pneumonia vs. Aspiration Pneumonia; Cataract bilateral Clinical Impression
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Differential Atherosclerotic thrombotic occlusive disease Brain Neoplasm Subarachnoid hemorrhage d/t cerebral aneurysm Brain Abscess Hypertensive encephalopathy
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Noncontrast CT scanning MRI Conventional x-ray cerebral angiography Paraclinicals (CVD)
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Blood studies -- to assist in identifying possible causes of stroke: CBC Coagulation studies Paraclinicals (CVD)
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Semiquantitative cultures from bronchoalveolar lavage (BAL) samples. Chest X-Ray Paraclinicals (HAP)
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Upon admission: Check ABC IVF of 0.9 NSS 1 liter x 16 hours NPO Monitor the vital signs and pupil size every hour. Management (CVD)
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Therapeutics: Oxygen Mannitol H2 blocker or Proton pump inhibitors Control Blood Pressure Management (CVD)
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Consider intubation if with noisy breathing or deterioration of level of sensorium. Consider neurological evaluation for large putaminal, lobar and cerebellar hematomas and for AV malformation. Anticonvulsants Hyperventilate if intracranial pressure is elevated. Management (CVD)
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Monitor glucose level Evacuation of hematoma Endovascular therapy Placement of an intraventricular catheter for cerebrospinal fluid drainage Smoking cessation, a low-fat diet and healthy lifestyle BP Lowering measures Management (CVD)
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Ceftriaxone (2 g IV q24h) or Moxifloxacin (400 mg IV q24h) Ciprofloxacin (400 mg IV q8h), or levofloxacin (750 mg IV q24h) Ampicillin/sulbactam (3 g IV q6h) or Ertapenem (1 g IV q24h) Management (HAP)
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RISK FACTORS: 69 years old, Male Hypertension Familial History of hypertension, and stroke No regular exercise Former smoker Occasional alcoholic drinker Algorithm Atherosclerosis Hyaline artheriolosclerosis in small penetrating arteries Hypertension BP: 200/100mmHg Vulnerability to damage
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Vulnerability to damage Rupture to deep penetrating arteries in the brain ↑ Intracranial pressure Intracranial hemorrhage Hypertension Brainstem compression
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↑ Intracranial pressure Brainstem compression Drowsiness Compression of blood supply Headache Intracranial hemorrhage ↓ Blood flow
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↓ Blood flow Ischemia Neuronal Cell Death
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Involvement of Right Basal Ganglia (Putamen) Contralateral Hemiparesis Facial Palsy Slurred Speech Left arm and leg weakness