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General Data

General Data. I.B. 54/M Right-handed farmer From Abra Transferred to our institution due to CT scan findings of subarachnoid hemorrhage. History of Present Illness. 1 month PTA (3/14/2010) (+) dizziness, (+) syncope, (+) severe headache, VAS 10/10, (+) left-sided weakness

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General Data

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  1. General Data • I.B. • 54/M • Right-handed farmer • From Abra • Transferred to our institution due to CT scan findings of subarachnoid hemorrhage

  2. History of Present Illness • 1 month PTA (3/14/2010) • (+) dizziness, (+) syncope, (+) severe headache, VAS 10/10, (+) left-sided weakness • Brought to a local hospital (Abra Provincial Hospital) and treated as a case of CVD • A CT scan done in Vigan ten days post-event revealed subarachnoid hemorrhage and aneurysm

  3. History of Present Illness • 1 month PTA • At this point, (-) sensorial changes, (+) minimal nape pain, (-) facial asymmetry • The patient was advised transfer to PGH for further evaluation and surgery • Patient opted not to consult due to financial constraints

  4. History of Present Illness • 2 weeks PTA • The patient was discharged asymptomatic after two weeks • 1 week PTA • The patient had sudden onset, persistent, piercing headache, (-) radiations, VAS 10/10, patient made no note of relieving or aggravating factors, (-) medications taken

  5. History of Present Illness • 1 week PTA • Consulted again in Abra Provincial hospital, admitted for three days, given unrecalled medications with some pain relief • Patient opted to take physician’s advice to seek consult in our institution

  6. Past Medical History • (-) previous diagnosis of HPN, but with note of hypertensive episodes on casual checking of blood pressure; no consults done • (-) DM / PTB / BA / allergies

  7. Family Medical History • (+) HPN – siblings • (-) DM / PTB / BA / allergies

  8. Personal/Social History • (-) smoking • (-) alcoholic beverage consumption • (-) illicit drug use • Married with 6 stepchildren, 3 biological children

  9. Review of Systems • (-) fever • (-) cough • (-) colds • (-) DOB • (-) abdominal pain • (-) bowel changes • (-) dysuria • (-) jaundice • (-) weight loss • (-) tinnitus • (-) blurring of vision • (-) rash • (-) orthopnea • (-) easy fatigability

  10. Physical Examination • Conscious, coherent, not in distress • Vitals: 130/80 100 20 36.7oC • HEENT: pink conjunctivae, anicteric sclerae, (-) cervical lymphadenopathy, (-) masses, (-) nystagmus • Chest/Lungs: equal chest expansion, clear breath sounds, (-) rales/wheezes

  11. Physical Examination • CVS: (-) heaves/thrills, distinct heart sounds, normal rate, regular rhythm, (-) murmurs • Abdomen: soft, flat, nontender, normoactive bowel sounds, (-) masses/organomegaly • Extremities: pink nail beds, full equal pulses, (-) cyanosis/edema

  12. Neurologic Examination • Awake, coherent, oriented • E4V5M6 • Cranial Nerves • I – not assessed • II – pupils 3cm briskly reactive to light • III, IV, VI – full, equal EOM’s • V – intact V1-3, brisk corneals • VII – (+) facial asymmetry; shallow R nasolabial fold

  13. Neurologic Examination • Cranial Nerves • VIII – intact gross hearing • IX, X – intact gag, uvula midline • XI – good shoulder shrug • XII – tongue midline • Good muscle tone • Motor strength 5/5 on all extremities

  14. Neurologic Examination • 100% sensation on all extremities • DTR’s ++ • (-) Babinski reflex • (-) clonus

  15. Course in the Wards

  16. Course in the Wards

  17. Course in the Wards

  18. Laboratory Results • Blood Type: A+ • CBC • 4/23/10: Hgb 163, Hct 0.458, WBC 5.8, Plt 266, L 0.615, N 0.263 • 4/27/10: Hgb 115, Hct 0.321, WBC 9.41, Plt 248, L 0.878, N 0.079

  19. Laboratory Results • PT/ PTT (4/23/10) • PT: 11.5/10.5/>1.0/1.01 • aPTT: 34.7/34.4 • Blood Chemistry • 4/23/10: Glu 6.01, BUN 11.58, Crea 69, Na 132, K 3.7, Cl 90 • 4/26/10: BUN 3.99, Crea 52, Na 196, K 3.4, Cl 112

  20. Laboratory Results • U/A • 4/24/10: yellow, turbid, pH 8.0, Sp Gr 1.010, CHO (-), CHON (-), RBC 9, WBC 2, EC 2, Cast 0, Crystals 0, Bac 17

  21. Summary • 54 y/o male • Apparently well until he presented with headache and left-sided weakness • Initially managed as a case of CVD, but with findings of subarachnoid hemorrhage on CT scan done 10 days post event

  22. Summary • 4- vessel angiogram showed • Saccular aneurysm, L anterior cerebral artery-anerior communicating artery junction site, with light vasospasm • Aplastic A1 segment, R anterior cerebral artery, patent anterior communicating artery

  23. Four-Vessel Angiogram • The gold standard for evaluation of cerebral aneurysms • Four vessels: • R and L verterbral arteries • R and L carotid arteries

  24. Differential Diagnoses

  25. Subarachnoid Hemorrhage

  26. Management

  27. THANK YOU! 

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