UNIVERSITY OF SANTO TOMAS HOSPITAL
Clinical Division
España, Manila
Department of Neurology & Psychiatry
Admission #
Hospital #
Room/bed No.:
Patient’s name:
Age/Status/Sex:
Birthday:
Address:
10F00414
06-79-04
202-F
BERNAS, Roselyn Roy
29/M/F
01/14/1981
Brgy.
Inerangan,
Alaminos, Pangasinan
Filipino
R. Catholic
06/18/2010
Dr. Conde
Dr. Lim/Sunga
Nationality:
Religion:
Date of admission:
Consultant:
RIC:
Informant: Mother & Sister
Reliability: Good
Chief Complaint:
Dizziness
History of Present Illness
On the first week of May, patient started
to experience loss of appetite. Her diet
consisted mostly of coffee and bread. There were
no episodes of headache, vomiting and loss of
consciousness.
On the following week, patient started to
experience epigastric pain followed by episodes
of vomiting of previously ingested food. She
then started to have generalized body weakness.
On the third week of May, patient
consulted at a local hospital due to persistence
of symptoms where her condition was managed
medically as ulcer. However, the patient also
started to experience lightheadedness, hiccups
and one incident of syncope.
On May 12, 2010, persistence of symptoms
now accompanied with dizziness prompted consult
at a local hospital in Alaminos. She was then
managed
medically
because
she
was
also
hypokalemic. Patient had another episode of
syncope.
On May 13, 2010, patient transferred to
another hospital (Villaflor Hospital) in Dagupan
where her condition was managed medically as
Acute
Gastritis/GERD.
Ancillary
procedures
(Chest Xray, Abdominal UTZ and EGD) were
requested
and
medications
(clarithromycin,
Pariet and spironolactone (Aldactone) were given
to address the present condition. Patient was
discharged after five days but still slightly
symptomatic.
On May 18, 2010, patient had dizziness
with accompanying blurring of vision but no
consult was done.
On June 10, 2010, patient had 3 episodes
of vomiting after the patient shifted to a full
diet. Patient was then compliant with her
medications. However, there was progression of
body weakness and now could only walk with
assistance. Patient went to a herbolario and was
given an herbal medication in place of the
prescribed
medicines.
However,
there
was
persistence of dizziness noted upon standing and
moving.
On June 15, 2010, dizziness is now
accompanied
with
dysphagia,
excessive
oral
secretions and slurring of speech. She then
again consulted at Villaflor hospital and was
managed medically. However, patient developed
febrile episodes and persistence of symptoms
thus, she was referred to our institution hence
subsequent admission.
Review of Systems:
(+) weight loss, (+) weakness
No rashes, no jaundice
No cough, colds, nasoaural discharge
No dyspnea, no orthopnea,
No chest pain, palpitations
(+) dysphagia, (+) abdominal pain
No hematuria, no frequency
No heat or cold intolerance, no polyuria, no
polydipsia, no polyphagia
No joint pains, no swelling
(+) slurring of speech
(+) dizziness, but no loss of consciousness,
seizure, tinnitus, diplopia
Personal and social history
Mixed diet but prefers sour foods
Non-smoker, occasional beverage drinker
Housewife
Past Medical History
(+) PUD
Not known hypertensive nor diabetic
Family History:
(+) DM – father
(+) HPN- mother
(+) Stroke - father
Physical Examination on Admission:
Conscious, coherent, non-ambulatory, not in
cardiorespiratory distress
VS: BP: 120/80 PR: 96 bpm, regular
RR: 16
cpm, regular
T: 36.80C
Wt: 50
Ht: 158
BMI: 20
Warm, moist skin, (-) active dermatoses, (-)
jaundice
Pink palpebral conjunctivae, anicteric sclera
(+) difficulty in phonation and articulation
Supple
neck,
no
palpable
cervical
lymphadenopathy, thyroid not enlarged
Symmetrical chest expansion, (-) retractions,
clear and equal breath sounds
Adynamic precordium, AB at 5th LICS AAL, S1>S2
apex, S2>S1 base, (-) murmurs
Flabby abdomen, NABS, soft, no palpable mass, no
tenderness on palpation
Pulses full and equal, no cyanosis, no edema
Neurologic Examination
Awake, prefers to keep both eyes closed,
dysarthic, dysphonic, can follow commands,
GCS15 (E4V5M6)
Olfactory nerve intact, pupils 2-3mm isocoric &
ERTL, EOMs intact, (-) papilledema,(+)
nystagmus (bilateral), no facial asymmetry,
V1-V3 intact, intact gross hearing, (-) gag
reflex, can shrug both shoulders, difficulty
in tongue protrusion
(+) dysmetria, dysdiadochokinesia
MMT: 4-5/5 on all extremities
Reflexes: ++ on all extremities
No abnormal reflexes
No sensory deficit
No nuchal rigidity
Assessment
Brainstem lesion probably:
demyelinating disease
Plans:
Cranial MRI with contrast
CBC with PC
Serum Na, K, BUN, Crea, Mg
Prepared by:
Harry M. Gabuat
infarct,
glioma,