case 1 doc gonsalves

8/17/2019 Case 1 Doc Gonsalves

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LYCEUM-NORTHWESTERN UNIVERSITY

DR. FRANCISCO Q. DUQUE MEDICAL FOUNDATION

COLLEGE OF MEDICINE

Dagupan City

G!up F

ARENAS, Joanne M. GANGAN, Monique

CARANAY, Francis Neil MEIMBAN, Giuzeppe Edrei

DIFN!"RM, Ma# Anne SANE$ARA, Ja#

!"NG"%, E&

Dat" !# int"$i"%& F"'uay ()* +)(,

""pt!& D. /u0" G!n1a2$"1

SURGICAL HISTORY

Ca1" 3(

GENERAL DATA

!'is is ('e case o) M.M, *+ #ears old, ale, Filipino, Roan Ca('olic, arried, (ric#cle dri-er,residin a( Alcala, $anasinan and adi((ed )or ('e second (ie a( Reion + Medical Cen(er on Fe/ruar#

*, 01+2 around 3 AM.

CHIEF COMLAINT& /leedin in ('e ri'( ear

HISTORY OF RESENT ILLNESS

N"I4 Maulin

D"I4 Fe/ruar# 10, 01+2

!"I4 +14*1 $M

$"I4 !arlac Ci(#

Fi-e 'ours prior (o adission, ('e pa(ien( 5as suddenl# a((ac6ed /# 0 drun6ards 5'ile 5al6in

alon ('e s(ree( a)(er /u#in oods )ro a s(ore. A plan( po( 5as sas'ed on ('e ri'( (eporo7parie(al

area o) 'is 'ead and 5as /ea(en 5i(' a /a/oo pole a( 'is le)( ('i' and le)( ar. 8e e9perienced /lurrin

o) -ision and (inni(us )or appro9ia(el# +1 seconds /u( anaed (o s(a# conscious. 8e no(iced /leedin

)ro ('e ri'( (eporo7parie(al area o) 'is 'ead, 5'ic' 'e percei-ed (o /e pain)ul. 8is ri'( ear and nose

also /led. 8e also e9perienced nu/ness in 'is le)( 'and. No associa(ed loss o) 'earin, nausea and

-oi(in. 8e s(ill anaed (o run a5a# and 5en( 'oe. No edica(ions (a6en and no edical

consul(a(ion 5as done.

!'ree 'ours prior (o adission, ('e pa(ien( 5as /rou'( (o a 'ospi(al in Ba#a/an, $anasinan.

!'e pa(ien( 5as said (o /e drun6 and 5as o/ser-ed.

"ne 'our prior (o adission, due (o una-aila/ili(# o) a C! scan in ('e said 'ospi(al, ('e pa(ien(5as (rans)erred (o R+MC 5'ere 'e 5as ('en adi((ed.

AST MEDICAL HISTORY

8is )irs( 'ospi(al adission 5as +: #ears ao ;+


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8is second 'ospi(al adission 5as + #ear ao> pa(ien( e9perienced di))icul(# o) /rea('in a)(er

drin6in a coca7cola so)( drin6. 8e 5as 'ospi(alized in a pu/lic 'ospi(al in Ba#a/an )or : da#s.

Medica(ions 5ere unrecalled.

$a(ien( claied (o 'a-e cople(ed 'is c'ild'ood -accina(ions /u( 5ere unrecalled. No no(ed

c'ic6enpo9, ups and easles durin 'is c'ild'ood. No 6no5n aller# (o an# )ors o) allerens suc'as )ood, drus, drin6s or e-en en-ironen(.

FAMILY HISTORY

$a(ien( is ('e #ounes( aon * si/lins. 8is )a('er, 21 #ears old, 5as a 6no5n '#per(ensi-e

5'ile 'is o('er died due (o leu6eia a( ('e ae o) 3?. 8is eldes( /ro('er died due (o an unrecalled

disease. "('er si/lin 5as apparen(l# 5ell. No o('er 'eredo)ailial diseases li6e au(oiune disease,

/lood d#scrasia, CAD, DM, lun and li-er diseases 5ere no(ed.

ERSONAL* SOCIAL AND ENVIRONMENTAL HISTORY

!'e pa(ien( is a 'i' sc'ool radua(e and 5or6s as a (ric#cle dri-er. 8e is a non7so6er. 8edrin6s in and@or /eer e-er# ni'( a)(er 5or6, consuin a /o((le o) /eer and@or 'al) a /o((le o) in.

8e usuall# consues + cup o) rice per eal and pre)ers ea(in por6 or /ee). 8e drin6s a cup o)

co))ee durin /rea6)as(. 8e li-es 5i(' 'is 5i)e, son, and in7la5s in a /unalo5 'ouse ade o) li'(a(erials. !'eir source o) drin6in 5a(er is )ro a 5a(er pup.

REVIEW OF SYSTEMS

General ;7= Bod# 5ea6ness

;7= S5ea(s

;7= ei'( loss

;7= C'ills

;7= Fa(iue

;7= Fe-er

;7= Decrease

Appe(i(e

SIN ;7= Jaundice

;7= $allor;7= r(icaria

;7= 8ea(oa

;7= C#anosis;7= Bleedin

;7= Sores

;7= %esions

;7= $ruri(us

;7= Ras'es

8EAD and

NEC

;7= Nodules

;7= $ain

;7= S(i))ness ;7= S5ellin

;7= Alopecia

4-5 Di66in"11

4-5 7"a0a7"

EYES ;7= As#e(r#

;7= Ic(eric Sclera

;7= Blurr# ision

;7= In)ec(ion

;7= I(c'iness

;7= Redness

;7= $ale

con&unc(i-a

;7= $ain

;7= Correc(i-es

;7=%acria(ion

;7= Diplopia

;7= Glaucoa

;7= Ca(arac(

EARS ;7= 8earin %oss

;7= In)ec(ion

;7= !inni(us

;7= 8earin Aid

;7= $ain

;7= Disc'ares

;7= er(io

N"SE ;7= Dr#ness;7= $ain

;7= Bleedin;7= Sneezin

;7= I(c';7= "/s(ruc(ion

;7= Disc'are

M"!8 ;7= Soreness;7= Gu /leedin

;7= "d#nop'aia

;7= 8oarseness;7= D#sp'aia

;7= $ain;7= Den(ures

;7= Dr#ness;7= In)ec(ion

RES$IRA!"RY ;7= Cou'

;7= 8eop(#sis

;7= 8#perpnea

;7= D#spnea

;7= 'eezin

;7= S(ridor

;7= C#anosis

;7= !ac'#pnea

;7= E9posure (o

;7= $ain

;7= Spu(u


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respira(or# 'azards

CARDIAC ;7= $alpi(a(ion

;7= Edea

;7= Anina ;7= C'es( pain ;7= "r('opnea

ASC%AR ;7= aricose eins ;7= $'le/i(is ;7= lcers ;7= Claudica(ions

GI! orABD"MEN

;7= $ain4-5 Nau1"a

;7= Cons(ipa(ion

;7= Rec(al $ain

;7= Anore9ia;7= %BM

;7= 8eorr'oids

;7= Dar6 S(ool

4-5 V!8iting;7= Melena

;7= 8ernia

;7= E9cessi-e

Belc'in

;7= 8ea(oc'ezia;7= 8ea(eesis

;7= 8ear( Burn

;7= E9cessi-e

Fla(us

RENA% orRINARY

;7= D#suria;7= $ol#uria

;7= 8ea(uria;7= Noc(uria

;7= Flan6@ Bac6 $ain;7= Inco(inence

;7= Anuria;7= "liuria

GENI!A%IA ;7= $ain

;7= Irri(a(ion@i(c'iness

;7= S5ellin

;7= lcer

;7= Disc'are

;7= I(c'in

;7= In)ec(ion

MSC%"7

SE%E!A%

;7= A(rop'#

;7= Craps

;7= S(i))ness

;7= $ain

;7= Join( $ain

;7= Nu/ness

;7= Frac(ures

;7= Bac6 and Flan6

$ain

;7= ea6ness

;7= Sprains

;7= !raua

ME!AB"%IC ;7= 8ea( or Cold

In(olerance

NER"S 4-5 S"i6u"1

;7= !reors

;7= $ain

;7= $aral#sis

4-5 Syn!p"

;7= Con-ulsions

;7= Mo(or, Sensor#,

or eor#

pro/les

EM"!I"NA% ;7= An9ie(#

;7= Idea(ions

;7= Insonia

;7= 8allucina(ions

;7= Depression

;7= S(ress

;7= Suicidal

HYSICAL E9AMINATION

G"n"a2 Su$"y4 $a(ien( is ediu /uil( uscular #oun adul( an seen l#in on /ed, in 'ospi(alclo('es, a5a6e and conscious. 8e is no( in cardiopulonar# dis(ress.

Vita2 1ign1

RR +< cp T"8p *2.21 C

R ?+ /p SaO+


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S;in4 S6in is /ro5n. i(' ul(iple lacera(ions. Does no( presen( 5i(' clu//in or c#anosis.

HEENT&

8ead4 Norocep'alic. Noral 'air dis(ri/u(ion. %inear lacera(ion 0.3c ri'( (eporal7parie(al area a/ou(

+1c superior (o ('e ear, uns(i(c'ed. %inear lacera(ion .3c )ore'ead.

E#es4 $alpe/ral con&unc(i-a is pin6. Anic(eric sclera. No opaci(ies, e9uda(es nor 'eorr'aes. $upils

equall# reac(i-e (o li'( and accooda(ion.Ears4 No s6in lesions, de)ori(ies, disc'ares, s5ellin, )orein /odies nor (enderness, no la(eraliza(ion.

Nose4 s#e(rical, sep(u in idline, no sins o) in)laa(ion. No disc'are, nor sinus (enderness.

Mou('4 Mois( /uccal ucosa, no ulcera(ions no(ed. No as#e(r# as res(.

!'roa(4 pin6 oral ucosa. $'ar#n9 is no( er#('ea(ous, no e9uda(es.

Nec64 !rac'ea is idline. !'e nec6 is supple. !'#roid is('us is idline. No l#p' node enlareen(

no(ed.

C7"1t an0 Lung1& No di))icul(# o) /rea('in. S#e(ric rise and )all o) c'es( durin respira(ion. No

ad-en(i(ious /rea(' sounds.

Ca0i!$a1u2a& Ad#naic precordiu, $MI a( 3 (' ICS MC%. Reular cardiac r'#(', noral ra(e

no(ed. Noral S+7 S0 no(ed.A'0!8"n& A/doen is )la(> Noroac(i-e /o5el sounds. %i-er span is 2c a( ri'( MC%. No (enderness

or asses on all quadran(s.

E


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CN • Sensor#4 ;= li'( (ouc' and pain sensa(ion in +, 0 and *

CN II

S8i2" i1 a1y88"ti- 0"$iat"0 t! t7" ig7t !n2y

• Blo5in uscle ;/uccina(or= is in(ac( le)( and ri'(

• Fron(alis uscle is in(ac(4 $a(ien( can 5rin6le 'is )ore'ead

CN III

W"'" t"1t& 1!un0 i1 7"a0 2!u0" !n t7" ig7t

• 4-5 Rinn" t"1t& '!n" !n0uti!n ? ai !n0uti!n !n t7" ig7t 1i0"CN IH and H •;7= di))icul(# in spea6in or s5allo5in

•;7= 'oarseness or 'us6# -oice

CN HI •S(ernocleidoas(oid and (rapezius are in(ac(

CN HII •!onue 5'en pro(ruded is in ('e idline ;no de-ia(ions=

•A/le (o o-e (o all direc(ions

MOTOR FUNCTION

SENSORY FUNCTION

• %i'( (ouc' usin a so)( /rus' 5as percei-ed in all par(s o) ('e /od#

• $ain usin pin pric6 5as percei-ed in all par(s o) ('e /od#

INITIAL IMRESSION& TRAUMATIC :RAIN IN/URY p!'a'2y CERE:RAL CONTUSION

4MILD5

Bases4

• 'is(or# o) 'ead in&ur#

• In&ur# (o ('e (eporo7parie(al /one ;lacera(ion and /leedin=7 ig7t 1i0"

• %a(eral rec(us pals# ;CN I=7 /o(' e#es

• Blurrin o) -ision7 /o(' e#es

• Ipaired -isual )ields

• As#e(ric sile pro/a/l# )acial ner-e ;CN II= pals#


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• Bone conduc(ion /e((er ('an air conduc(ion7 ig7t "a

• !inni(us

• GCS+3 ;ild 'ead in&ur#=

•Mild con)usion, slo5 (o )ollo5 ins(ruc(ions

DIFFERENTIAL DIAGNOSES

Rule In Rule "u(

Cere/ral concussion !raua (o 'eadBlurrin o) -ision

Ipaired -isual )ield

Nu/ness

• acan( s(are

• Con)usion

• Meor# de)ici(

• Disorien(a(ion

• Dela#ed o(or and -er/al

responses• 8eadac'e

• Nausea or -oi(in

• %ac6 o) a5areness

• Dizziness

In(racere/ral

'eorr'ae

!raua (o 'ead

Blurrin o) -ision

Ipaired -isual )ield

Nu/ness

• sudden 5ea6ness, (inlin, or

paral#sis in ('e )ace, ar, or le,

• sudden onse( o) se-ere 'eadac'e

• loss o) /alance and coordina(ion,

dizziness

• nausea, -oi(in

• loss o) consciousness• con)usion, deliriu

MANAGEMENT

La'!at!y %!;up1&

C!4 C! pro-ides rapid, nonin-asi-e iain o) ('e /rain and s6ull. C! is superior (o MRI in -isualizin

)ine /one de(ail in ;/u( no( ('e con(en(s o)= ('e pos(erior )ossa, /ase o) ('e s6ull, and spinal canal.

MRI4 MRI pro-ides /e((er resolu(ion o) neural s(ruc(ures ('an C!. !'is di))erence is os( sini)ican(

clinicall# )or -isualizin cranial ner-es, /rain s(e lesions, a/norali(ies o) ('e pos(erior )ossa, and ('e

spinal cord.

S6ull Hra# (o see pro/a/le )rac(ure

CBC 5i(' /lood (#pin (o see 'eolo/in and 'ea(ocri( le-el (o assess ('e /leedin, and /lood (#pin

)or ipendin cross a(c'in i) (rans)usion is needed 5'en surical opera(ion is (o /e done.


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$!@a$!! (o de(erine an# a/norali(ies ('a( a# cause coaula(ion pro/le

Seru elec(rol#(es a# e9acer/a(e /rain in&ur# and a# require correc(ion.

De(erine Mean ar(erial pressure

"rder o) urenc#4

• Surer# (o con(rol /leedin in and around ('e /rain

• Moni(orin and con(rollin in(racranial pressure

• Insurin adequa(e /lood )lo5 (o ('e /rain

• !rea(in ('e /od# )or o('er in&uries and in)ec(ion

A. MEDICA%

• A5a6en pa(ien( e-er# 0 'ours and assess neuroloicall# )or an# sins o) de(eriora(ion

• Manni(ol ;diure(ics= (o decrease /rain -olue and cere/ral edea

B. SRGICA%

• Relie) o) in(racranial pressure -ia cranio(o#

• en(riculos(o# a# also /e done (o increase in(racranial pressure

case 1 doc gonsalves

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