Case Pres - Basal Ganglia ICH

PATIENTS HISTORY AND DEMOGRAPHICS

Patients Name: R.I.F.Sex: MAge: 50Date of Birth: May 17, 1964Religion: CatholicAddress: 79-E San Antonio St., S.F.D.M., Quezon CityCivil Status: MarriedOccupation: DriverDate of admission: February 24, 2014

Chief Complaint: Dizziness with right-sided weakness

History of Present Illness:Patient is a known hypertensive for 10 years. He was prescribed with Metoprolol 50 mg/tab, OD but was not compliant. He had a previous episode of stroke (2009) which presented with slurring of speech and right-sided weakness.11 hours prior to admission, while drinking alcohol with friends, the patient suddenly felt dizzy and experienced right-sided weakness which prompted his friends to call his children. After coming, the children noticed that there is worsening of the patients slurring of speech and that there is facial asymmetry. No vomiting, loss of consciousness.10 hours prior to admission, patient was brought to Novaliches General Hospital where cranial CT was done which showed intracerebral hemorrhage. However, due to lack of facilities and an available surgeon, they were referred to Quezon City General Hospital.7 hours prior to admission, patient was brought to Quezon City General Hospital, where he was immediately referred to East Avenue Medical Center again due to lack of facilities.6 hours prior to admission, patient now brought to East Avenue Medical Center where he was referred to our institution due to lack of rooms.4 hours prior to admission, the patient now brought to our institution wghere a repeat cranial CT was done which showed no change in the intracerebral hemorrhage. The patient also was hypertensive (highest BP: 220/110). Due to persistence of symptoms and CT scan findings, patient was admitted.

Review of Systems:General Survey(-) Undocumented weight loss(-) Loss of appetite

Cutaneous (-) Hair Loss(-) Rashes(-) Jaundice

HEENT(-) Excessive salivation

Respiratory (-) Difficulty of Breathing(+) Cough

Cardiovascular (-) Cyanosis, orthopnea(-) PND

Gastrointestinal (-) Nausea(-) Vomiting(-) Diarrhea(-) Constipation(-) Melena(-) Hematemesis(-) Hematochezia

Genitourinary (-) Frequency(-) Hematuria(-) Nocturia

Endocrine(-) heat or cold intolerance

Musculoskeletal (-) Edema

Hema(-) Pallor(-) Petechiae(-) Gum Bleeding(-) Easy Bruising

Past Medical HistoryCurrent Illness: Hypertension (2004) maintained on Metoprolol 50 mg/tab, 1 tab OD not compliant DM no medicationsPrevious hospitalization CVA (2009)No allergiesNo previous blood transfusionsNo previous surgeries

Family History(+) Hypertension - paternal and maternal(+) DM paternal

Personal/Social History Smoking history: smokes 2-3 sticks per day Alcohol intake: occasional alcoholic beverage drinker Denies illicit drug use

Physical Exam on Admission General: GCS 11 (E3 V2 M6), lethargic, stretcher-borne Vital signs: BP=220/120, PR=91, RR=20, Temp.=36.0 Anthropometric data: Ht.= 162 cm; wt. 75 kg; BMI=28.1 kg/m2 (Overweight) Skin: warm, dry skin, no active dermatitis, good skin turgor Head: normal hair distribution, no scalp lesions, no swelling, no deformities Eyes: pink palpebral conjunctivae, anicteric sclera, pupils 1-2 mm ERTL Ears: no deformities, no aural discharges, no tragal tenderness Nose: no nasal flaring, nasal septum at midline, no nasal discharge Neck: no neck vein distention, no thyromegaly, no masses, no palpable lymphadenopathy Lungs: symmetrical chest expansions, no subcostals and intercostals retractions, clear breath sounds Heart: adynamic precordium, apex beat at 6th LICS AAI, S1>S2 at apex, S2>S1 at the base, no murmurs, no thrills, no heaves, no lifts GI: flat abdomen, normoactive bowel sounds, tympanic in all quadrants, soft, no palpable mass, no tenderness Extremities: no deformities, no edema

Neurological Exam GCS 11 (E3 V2 M6), awake, wheel chair-borne Cranial Nerve I not assessed II pupil 1-2mm ERTL III, IV, VI EOM full and equal, (+) visual threat V can clench teeth but stronger on left side VII facial asymmetry, shallow right nasolabial fold VIII gross hearing intact IX, X (+) gag reflex, uvula not assessed XI can shrug shoulders, but stronger on the left side Motor: 5/5 LUE, 5/5 LLE, 4/5 RUE, 4/5 RLE, (+) RUE and RLE drift Cerebellum: cant be assessed Sensory: RUE and LLE sensory deficit Reflexes: ++ DTR on all extremities Meningeal: (-) Kernigs sign, (-) Brudzinski sign, (+) babinski right side

Initial assessmentLeft basal ganglia Intracerebral hemorrhage, Hypertension stage 2 uncontrolled, Diabetes Mellitus type 2 uncontrolled.

COURSE IN THE WARDDATEPHYSICIANS ORDER SHEETNURSES NOTES

FEBRUARY 20, 2014

Please admit under the service of Dr. Enrile NPO IVF: 1L PNSS 30 gtts/min Monitor VS, GCS, and pupils Q2 Monitor I and O every shift Request for the following:- CBC -N/K/Ca-PT/PTT -CXR-12L ECG Repeat cranial CT scan Medications: Mannitol Ranitidine Paracetamol Maintain SBP between 110 to 140 mmhg Refer to CV med for evaluation and management Continue close neurologic monitoring Give Nicardipine via infusion SBP between 110 to 140 mmhg Request for FBS and lipid profilie, SGPT Increase paracetamol to 600mg Q6 RTC Turn patient to sides Q2, bedsore precaution Apply anti-embolic stockings Oral hygiene and betadine gargle QID Moderate to high backrest CBG Q6 while NPO

11:00AM (+) dizziness (+) elevated BP 190/100 (+)HPN 10 years (+) DM (+) TIA 4 years ago Non-smoker, non- alcoholic drinker

CV med Pt. seen and examined. History reviewed. Start Nicardipine 10mg in 90 cc PNSS to run initially at 10cc/hr to maintain SBP 110 to 140 mmHg Watch out for alterations in sensorium Monitor BP for 1 hour for now Inform us of any surgical plan

2:45 PM CV med Please include FBS in next blood drain Retrieve 12 L ECG Start CLONIDINE 75mg/tab sublingual 1 tab Q8hrs Titrate down NICARDIPINE drip to maintain SBP Suggest CBG monitoring Q8 Refer if with chest pain, chest heaviness

7AMF> For admissionD> admitted 49 y/o male with a CC of dizziness and R sided weakness under the care of Dr. Enrile; GCS= 11 (E3V3M5) with initial VS of 230/ 120, PR = 71, RR = 20, Temp = 36.0C, O2 Sat 98%; ht = 162 cm, wt = 75kgA> promote safety, side rails up; kept comfortable, started hydration PNSS 1L 30 gtts/min with drop factor of 20 infusing well; started Nicardipine drip 10 mg in 90ml PNSS infusing well ensured; CBC, PT, APTT, 12 lead ECG, Na K, creatinine, Chest x-ray, cranial CT scan facilitated.R> admitted

F> Admission careD> Admitted 40 y/0 male with diagnosis of Left basal ganglia intracranial hemorrhage; (+) right sided weakness with IVF of PNSS 1L @ 30 gtts/min & side drip of Nicardipine 10 g/IV in 90 cc PNSS to run at 10cc/hr to maintain BP of 110-140 (latest BP: 180/110) with IC-HB noted; GCS= 12-13; on NPOA> Oriented patient on hospital & work set up; IV fluid kept infusing well; Maintained on NPO as ordered; Monitored VS including GCS&PLR, especially BPR> GCS = 12-13, latest BP: 160/100

F> at risk for impaired cerebral tissue perfusionD> a case of Left basal ganglia ICH; GCS = 12-13 notedA> Monitored VS including GCS & PLR; Watched out for alteration/deterioration in sensoriumR> GCS= 12-13

7PMF> Risk for impaired cerebral tissue perfusionD> Known case of Left basal ganglia ICH; GCS = 12 notedA> Parameters taken and recorded; Monitored VS; Monitored for alteration in sensorium; Safety and fall precaution observed.R> GCS= 12-13 noted

10PMF> Impaired blood circulationD> with hypertension episodes; Latest BPA> Nicardipine titrated as ordered; Monitored VS; Promoted rest periods; Monitor for persistence of hypertension.R> Latest BP 120/80. Nicardipine at 10ml/hr

F> Risk for impaired cerebral tissue perfusionD> Known case of Left basal ganglia ICH; GCS =13 notedA> Parameters taken and recorded; Monitored for alteration in sensorium; Safety and fall precaution observed; Monitored hourly for GCS. R> GCS= 12-13 noted. Not in distress

FEBRUARY 21, 2014

CV med Start losartan 50mg/tab 1tab OD Aspiration precaution please Dec. clonidine 75mg/tab Q12 HSWatch out for BP elevation8AMF> impaired physical mobilityD> Known case of Left basal ganglia ICH; With right sided hemiparesis, unable to move to sides, requires assistance in changing positionsA> Assured in assuming position of comfort by placing on semi-fowlers position; Provided frequent change of position by turning to sides; Promoted passive ROM exercises; Ensured safety by raising side rails; Assisted in performing ADLs & self care related actiivites. Maintained adequate hydration; Observed for untoward signs of distress.R> Able to turn to sides with minimal assistance; no incidence of injury suring the shift; no untoward signs of distress

3PMF> Risk for altered cerebral tissue perfusionD> GCS = 12-13 (E3V3M6) noted. Stable VSA> Adequate rest periods promoted. Safety measures observed. Advised relatives to stay with patient at all times. Watched out for signs of distress.R> GCS=13 (E4V3M6) noted

11PMF> Risk for hypertensionD> received on Nicardipine drip A> Monitored for progression of elevated BP/HTN. Monitored for ALOC; Parameters taken and recorded; Monitored accordingly.R> with latest BP = 140/80; with no complaints; endorsed accordingly with preBF CBG = 83mg/dl. Advised to have cup of juice; Endorsed accordingly

FEBRUARY 22, 2014 NSV May start soft diet May start to try giving meds per orem Shift PARACETAMOL to 500mg Q6 Start LACTULOSE 30cc ODHS

9AMF> Risk for aspirationD> known case of left side basal ganglia ICH; shifted to soft diet from NPO; (+) R sided weakness; GCS = 14(E4V4M6)A> Place on semi-fowlers position with HOB 30 during meals; observed strict aspiration precaution. Instructed relative to start with clear liquid first before feeding. May have soft diet. Turned to side every 2 hours with anti-embolic stockings. Monitored for altered sensorium & chest pain. Advised to ask for assistance as needed. Safety precaution observedR> No reported incidence of aspiration during the shift

10:50 AMF> Impaired physical mobilityD> 3 days post-stroke; Known case of left basal ganglia ICH; Right sided weakness, able to turn to side but cannot tolerate lying on the left side; Maximal dependence on ADLA> Encouraged participation and self care such as intake of medications per orem; Assisted to frequent turning of positions every 2 hours; Encouraged ROM exercise; Encouraged participation in decision making and early ambulation

2:45 PMF> Impaired bed mobilityD> Known case of left basal ganglia ICH; GCS = 14 (E4V4M6); NO ambulation since admission; Warm moist skinA> Repositioned HOB at 15; Fixed linens and gowns; Turned to sides every 2 hours with anti-embolic stockings; Inspected for bed source; Kept skin clean and dry; Raised both side rails; Instructed relatives to be at bed side at all timesR> No signs of redness or erythema; Skin dry; Amenable

10:30 PMF> BP elevationD> Latest BP 150/100 mmHg on Nicardipine drip; GCS = 12 (E3V3M6)A> Continued titrating Nicardipine to maintain BP at 110-140; Continued GCS, VS and PLR monitoring; Watched out for signs of altered sensorium and increase ICPR> BP 150/100 mmHg; Continued titrating Nicardipine; GCS = 13 (E3V4M6)

FEBRUARY 23, 2014

CV med Inc. LACTULOSE to 45cc ODHS If still with no BM tomorrow may give Dulcolax suppository Start AMLODIPINE 5mg/tab OD Inc. losartan 50mg/tab BID Titrate down Nicardipine drip to maintain SBP 110 to 140 mmhg

11:30 AM GCS 15 -NSX- Consume nicardipine drip Inform med Full diet

BP=170/90 (+) light headedness-Cardio- Continue Nicardipine drip. Titrate by increments/ decrements of 5cc to maintain SBP 110-140mmHg

8:30 PM BP 150/100 HR78-Cardio-Inc. amlodipine to 10mg/tab ODInc. clonidine 60 75 mcg 1tab Q8Continue titrating nicardipine drip to maintain SBP to 110 to 140mmhg

7:00 AMF> Risk for altered cerebral tissue perfusionD> Known case of left basal ganglia ICH; GCS = 12 (E3V3M6); completely assisted; BP = 160/100 on Nicardipine dripA> Parameters taken and recorded including GCS, VS and PLR; Watch out for alteration and sensorium; Monitored for breakthrough headache; Monitored for persistence of BP elevation; Continued Nicardipine drip as ordered; Monitored accordingly R> GCS = 13; BP 140/90 mmHg; Endorsed

8:00 AMF> Impaired physical mobilityD> Known case of left basal ganglia ICH; Non-ambulatory with right sided hemiparesis; Unable to move to side; requires assistance in changing positionA> Assisted in assuming position of comfort by placing in semi-fowlers position; Provided frequent change of position by turning to side; Promoted passive ROM; Ensured safety by raising side rails; Assisted in performing ADLs and self-care related activities; maintained adequate hydration; observed for untowards signs of distressR> Able to turn to sides with minimal assistance; no incidence of injury during shift; no signs of distress noted

2:00 PMF> Hypertension D> On Nicardipine drip titrated as ordered; Monitored for persistence of elevation BP, Parameters taken and recorded; Monitored for ALOC; Monitored accordinglyR> With no complaints; With latest BP 170/100 mmHg; Endorsed accordingly; Referred to MROD

10:00 PMF> BP elevationD> Latest BP 170/100 mmHg on Nicardipine drip; GSC = 12 (E3V4M6) A> continued titrating Nicardipine; monitored for persistence of BP elevation; and altered sensoriumR> with latest BP 130/90 mmHg; GCS = 12 (E3V4M5)

FEBRUARY 24, 2014

Dec. mannitol to 100cc/IV Q8 x 3 days then decrease to Q12 x 2 doses IVF to consume after mannitol is finished May remove IC now Refer to rehab med for active PT11:00 AM Accurate I and O please Increase amlodipine to 10mg 1 tab OD Give the following medications: Losartan 50mg/tab BID Clonidine 75mg/tab Q8 Diet 30kcal/kg/day divided into 3 meals 2snacks Inc. lactulose 45cc ODHS Inc. OFI Aspiration precaution

9:00 AMF> HypertensionD> BP 150/90 mmHg on Nicardipine dripA> Continued titrated Nicardipine to maintain BP 110-140 mmHg; Instructed to avoid straining. Encouraged to do DBE. High backrest. Monitored accordinglyR> BP 140/ 90 mmHg. Still on Nicardipine drip @ 20 cc/hr

2:00 PM F> Risk for altered cerebral tissue perfusionD> (+) slurred speech; GCS 14-15; with movements of disorientation; On Nicardipine drip titrated as advisedA> Monitored for ALOC & headache, Parameters taken and recorded. Monitores accordinglyR> with latest BP__; with no complaints; still with moments of disorientation. Endorsed accordingly

F> Risk for altered cerebral tissue perfusionD> known case of left basal ganglia ICH; GCS 13-14A> Monitored VS including GCS & PLR; Watched out for alteration/deterioration in sensoriumR> GCS 14-15 noted; Stable VS

FEBRUARY 25, 2014

8:30 AMCV med Encourage DBE Aspiration precaution Titrate down nicardipine to maintain SBP 110 to 140 mmhg Suggest to request 2D echo 2/25/14(6pm) Patient seen and examined. History reviewed We will start physiotheraphy once Bp is stable We plan to start P.T for quadral upright mobilization and O.T for dysarthia

6:00 PM-NSX- Repeat Na, K, crea tomorrow 3am May do 2D echo as suggested Include HBA1C tomorrow Start atorvastatin (Lipitor) 40mg/tab ODHS Paracetamol to Q8 RTC Nicardipine drip to consume10:00 AMF>Risk for aspirationD> known case of left side basal ganglia ICH; with slurred speech and right hemiparesis; verbalized difficulty in swallowingA> Positioned on high-fowlers during meals;Instructed to have a soft diet nad thick fluids;Chew foods thoroughly on the strong side (left side) and flex the neck upon swallowing. Instructed to wait2 for 30 mins- 1hour before changing position from high-fowlers to flat on bed.R> No aspiration after meals and no symptoms of DOB was noted during the shift, VS 180/80,PR 90, RR 20, Temp 36.8

2:30PMF> risk for altered cerebral tissue perfusionD> a case of basal ganglia ICH; GCS 12 (E4V3M5); BP 130/90A> Monitored GCS, NVS, PLR, monitored for alteration in sensorium and BP elevationR> latest BP = 140/90 mmHg

8:00 PMF> Risk for altered cerebral tissue perfusionD> a case of left basal ganglia ICH, GCS !%. Positive slurred speech and right hemiparesisA> Monitored VS hourly including GCS, PLR; Watched out for alteration and deterioration in sensoriumR> GCs 14-15 noted

FEBRUARY 26, 2014

7:00 AM-NSX- May bring patient to AMRC for active PT

7:55 AM -Rehab med- For initial PT and OT today Please continue bedside ROM and lingual exercises Continue proper bed positioning,deep breathing.

9:40 AM K=3.43-CV med- Continue accurate I and O Inc. sources of K in diet Inform UT once patient is brought to heart station for 2D echo Realay initial reading once available Aspiration prec. Please Refer if with chest pain/dyspnea

7:00 AMF> Risk for hypertensionD> previously on Nicardipine drip: a case of left basal ganglia ICHA> monitored for elevation of BP & ALOC; Parameters taken and recorded & monitored accordinglyR> GCS 14 (E4V4M6) still with slurred speech noted; latest BP 140/100

3:15PMF> risk for altered cerebral tissue perfusionD> known case of left basal ganglia ICH; GCS 14 (E4V4M6) partially assistedA> parameters taken and recorded including GCS, NVS, PLR; watched out for alteration in sensorium; assisted in ADLs; monitored for breakthrough headache, elevation in BP; Monitored accordinglyR> GCS 14; BP 130/90mmHg

10:00PMF> Risk for altered cerebral tissue perfusionD> a case of basal ganglia ICH; GCS 14 (E4V4M6); BP 130/90A> Monitored for sign of increased ICP & alteration in sensorium. Safety precaution observed. Continued GCS monitoringR: GCS 14 (E4V4M6)

FEBRUARY 27, 2014

7:05 AM-NSX- Dec. paracetamol to PRN Q6 for head ache Confirm PT of AMRC Continue close neurologic monitoring7:30AM-Rehab med- Will continue PT today Facilitate OT today Continue proper bed positioning Encourage deep breathing when walking10:52 AMCV med Follow up 2D echo with Doppler results please incorporate to chart Continue oral anti-hypertensive WOF for BP elevation

8:00AmF> Risk for injuryD> weakness on both upper & lower extremities; completely assistedA> side rails raised and padded; continued physical therapy as ordered; assisted with ADLs; fall precaution observed at all times

3:00PMF> risk for altered cerebral tissue perfusionD> case of left basal ganglia ICH; GCS 14 (E4V4M6)A> parameters taken and recorded. Monitored for headache and elevation of BP. Watched out for alteration in sensorium. Safety & fall precautionR> GCS 15; BP 130/90

11:00 PMF> risk for hypertensionD> with oral meds as orderedA> monitored for elevation of BP; Encouraged sleep & rest; Parameters taken and recordedR> Latest BP = 120/80; with no complaints; endorsed accordingly

FEBRUARY 28, 2014

8:00 AM Noted plan for rehabilitation Aspiration precaution please Accurate I and O Refer if BP elevation Incorporate to chart 2D echo results9:00 AMRehab med Well continue physical therapy for sitting drills Still for initial O.T for dysarthia progress Please continue for syllabication exercises 7:00 AMF> risk for altered tissue perfusionD> GCS 14-15 (E4V4M6) notedA> adequate rest periods promoted; advised to avoid straining; Instructed to verbalize complaints; Safety measures are observed; Watched out for changes in sensoriumR>

LABORATORY RESULTS AND DIAGNOSTIC FINDINGSFebruary 20, 2014URINALYSIS

Ph 7.0Inference: NormalSpecific Gravity: 1.005Inference: Normal

BLOOD CHEMISTRY

Sodium: 133Range: 137-149Result: LOWDiuretic administration: Many diuretics work by inhibiting sodium reabsorption by the kidney. Sodium level is diminished Hyperglycemia: Each 60mg/100ml increase of glucose above normal decreases the sodium 1mEq/L, because the osmotic effect of the glucose pulls in free water from the extracellular space and dilutes sodium.

COAGULATION ASSAY

ALL RESULTS ARE NORMAL

COMPLETE BLOOD COUNT

HGB 172 g/LRange: 120-170Result: HIGHInference: Congenital heart disease: Cyanotic heart diseases case chronically low PO2 levels. In response, the Rbcs increase in number therefore Hgb increases

WBC: 13.20 x 10^9/LRange: 4.5 10Result: HIGHInference:Infection: WBCs are integral to initiating and maintaining the bodys defense mechanism against infection.

CHEST XRAY

Heart appears enlargedProbable cardiomegalyInference: The result of high blood pressure and coronary artery disease.

February 21, 2014Blood Chemistry

FBS: 123.90 mg/dlRange: