The Patient

The Patient:
Richard R. Reyes, a 55-year-old, right-handed male, and a resident of #16-S Quiling Sur, Batac City
is rushed in the emergency room per stretcher due to altered sensorium. He is accompanied by his son
and his daughter in-law.
History of Present Illness:

Six (6) hours prior to admission, patient was apparently well, able to eat his meals and perform
activities of daily living. There were no associated complaints.
Two (2) hours prior to admission, the patient went for a nap, still with no associated complaints.
The patient seemingly had a good sleep.
Few hours prior to admission, the patient woke up and complained of severe sudden dizziness,
with associated facial asymmetry and left-sided body weakness. The persistence of the aforementioned
symptoms with noted decreasing in sensorium prompted the family members to seek consult at the
emergency department. Mr. Reyes was subsequently admitted.
Past Medical/Surgical History:

Patient has (+) hypertension for 5 years: maintained on Telmisartan + HCTZ 80/12.5 mg/tab 1 tab
OD AM and Amlodipine 5 mg/tab 1 tab OD PM. However, the patient was non-compliant of his prescribed
pharmacologic regimen. The patient also did not visit the clinic for his regular follow-up check-ups.
The patient is also diabetic. He is diagnosed of DM Type 2 for 6 years: maintained on Metformin
500 mg/tab 1 tab BID and Gliclazide 60 mg/tab 1 tab once a day before breakfast. However, he was also
non-adherent with his prescribed regimen.
The last recent consult of the patient was noted to be 3 years ago when he sustained a small
wound on his left foot after it was accidentally pricked by a sharp object. He sought consultation in the
OPD of the facility, was prescribed with antibiotic, was advised, and was sent home. The patient did not
come back on his scheduled follow-up check-up. The patient has no previous hospitalizations. Neither did
the patient undergo surgical operations.
Family History:
(+) Hypertension and (+) DM Type 2 on both sides of the family
Social History:
 Known smoker for 8 pack years
 Known alcoholic, claims to consume 2-3 bottles of beer everyday
 Diet consists of fatty and salty foods, fond of drinking soda every day
1
 He is a Private Company driver
Physical Examination
Vital signs: BP – 220/130 mmHg, CR – 107 bpm, RR – 20 bpm, Body Temp. – 36.7oC, O2 Sat – 95%
Ht: 1.75 m
Wt: 84 kg
BMI: 27.45 (obese-Asia Pacific)
GCS: 9 (E3V1M5)
Skin: no active dermatoses
Head and Neck: anicteric sclera, pink palpebral conjunctiva, grossly normal ears and nose, no noted
discharges, no tenderness, no cervical lymphadenopathies
Chest and Lungs: RR – 20 bpm, symmetrical chest expansion, no retractions, clear breath sounds
Cardiovascular: adynamic precordium, CR – 107 bpm, irregular rhythm, PMI at 5th ICS MCL, no murmurs
GIT: globular, normoactive bowel sounds, soft, nontender abdomen
Extremities: full equal pulses, no deformities, no edema
Neuro: NIHSS =14
1a (1): patient is not alert but able to open both eyes with minor stimulation
1b (2): answered one question correctly
1c (1): able to obey one command (open-close eyes command)
5b (3): no effort against gravity with minimal movement
6b (3): no effort against gravity with minimal movement
8 (1): mild to moderate sensory loss; R side has a slower response to painful stimuli
9 (3): mute or global aphasia
2
PRIMARY WORKING IMPRESSION:
Hypertensive Emergency; Cerebrovascular Disease - Infarct vs. Hemorrhagic, Probably LMCA territory;
DM Type 2 Obese, Non-Insulin Requiring – poorly controlled
Hence the doctor ordered the following (ER LEVEL)

DOCTOR’S ORDER SHEET
10/25/2021  Please admit to ER holding area under the services of Dr. Ang/Dr. Borromeo/Dr. Cu
6 AM  Secure consent for admission and management
 Check CBG now and record – 342 mg/ dL
 Vital signs, GCS, NIHSS every 15 mins
 Temperature and CBG every 4 hours
 NPO for now
 Insert IFC aseptically connected to urine bag
 Stand by O2 support for SaO2 <95%; may start at 2-3 lpm per nasal cannula to
achieve SaO2 of >95%
 IVFluid: Start PNSS 1L for 12 hours; please use gauge 18 IV cannula
 Elevate head to 30 degrees
 Diagnostics:
CBC, PT/PTT, BUN, Crea, Na, K, ABO-blood typing
lipid profile, FBS, Urinalysis
12 leads ECG, CXR AP with highest truncal elevation
SARS COV test
plain cranial CT Scan STAT
CT Scan  Therapeutics:
revealed no Administer 10 units regular insulin IV now – recheck CBG after 30 minutes
bleed Start Nicardipine drip 10 mg in 100 mL solution at 10 mL/hr- increase 5 mL/hr every
15 minutes to maintain MAP of 110-130 mm Hg.
Start Enoxaparin 0.4 mL/ injection SC OD
Omeprazole 40 mg IV q 24H
 Watch out for progression of current neurologic deficits, new neurologic
deficits
 Refer CBGs of <140 mg/dL or > 180 mg/dL and temperature of >37.5 oC
 Refer to Rehab due to moderate stroke
 Follow up SARS COV Test; may trans in to MICU once with negative results
 Referred case to Dr. Neurologist, Dr. Cardiologist and Dr. Endocrinologist -
informed
 Refer accordingly
JM Dela Cruz, MD (Resident on Duty)
3
DIAGNOSTIC / LABORATORY RESULTS
ECG
CXR
4
Plain Cranial CT Scan
Urinalysis
Result Reference Range
Color Light yellow
Clarity Clear
Specific Gravity 1.010
pH 5.0
Chemical Exam
Protein Negative
Glucose +3
Hemoglobin +1
Ketone +1
Nitrite Negative
Bilirubin Negative
Urobilinogen Normal
Leuko Esterase Negative
Microscopic Exam
WBC 0-1 0.0-3.0
RBC 3-4 0.0-2.0
Epithelial Cells Rare 0.0-26.0
Bacteria Rare 0.0-278.0
Mucus Threads None
Yeast Cells -
5
Hematology
Chemistry
6
10/25/2021  Received from ER holding area
9 AM Present Working Impression: Hypertensive Emergency; CVD Infarct LMCA; DM
Type 2 Obese, Insulin Requiring; Atrial Fibrillation in RVR
>(-) SARS COV  Diagnostics: ALT, AST, 2D Echo
test  Hook to cardiac monitor
>Trans in from  Insert NGT; 2000 kcal/day divided into 6 equal feedings
ER Holding area  CBG TID and HS
>patient history  Therapeutics:
reviewed 1. Enoxaparin 0.4 mL/injection SC OD
>VS: 2. Rosuvastatin 20 mg/tab 1 tab OD HS per NGT
200/180 mmHg,
CR 90-110 bpm, 3. Lactulose 30 cc OD HSper NGT PRN x constipation
RR 24 bpm, 4. Omeprazole 40 mg IV OD
o
Temp 37 C
GCS: 10 5. RI Scale:
(E3V2M5) 180-220 mg/dL – 4 u SC
>Pupils 2 mm 221-260 mg/dL – 6 u SC
equally 261-300 mg/dL – 8 u SC
reactive, clear >300 mg/dL – refer
breath sounds, 6. Paracetamol 300 mg IV every 4 hours PRN for headache or temp > 37.8 oC
irregular 7. Continue Nicardipine drip to maintain MAP of 110-130
rhythm, (-)
murmur
NIHSS: 28
1a (1) 5b (4)
1b (2) 6a (2)
1c (1) 6b (4)
2 (1) 8 (1)
3 (2) 9 (3)
4 (2) 10 (2)
5a (2) 11 (1)
 Repeat Na in AM’s extraction

 Watch out for desaturation, dyspnea, hypotension and anisocuria
7
JM Dela Cruz, MD

10/25/2021  Hold feeding temporarily except meds
1 PM  Request for ABG and serum Na now
VS:  Prepare for endotracheal intubation then connect to MV with the following
180/100 settings:
mmHg, AC ModeRR: 12
CR 105 bpm, I/E: 1:2
R R 42 bpm, PEEP: 15
temp 37.7 oC, FiO2: 100%
O2 Sat 88%  Give Metoclopramide 10 mg/amp 1 amp IV now
GCS: 7  Increase paracetamol 300 mg IV to every 4 hours RTC
(E1V1M5)
(+) respiratory
distress
(+) vomiting
NIHSS: 28
 Repeat ABG post intubation
 Continue other medications
 May start Mannitol 200 cc IV bolus every 6 hours once with favorable Na
values
 Start Furosemide 20 mg IV 30 minutes every after mannitol
 Watch out for progression of dyspnea, desaturation, congestion and
hypotension
 Suction secretions as needed
 Bedsore precaution
 Repeat plain cranial CT scan in AM
JM Dela Cruz, MD
8
The National Institutes of Health Stroke Scale
NIHSS score: 0-5 (Mild Stroke)

NIHSS score: 6-21 (Moderate Stroke)
NIHSS score: ≥ 22 (Severe Stroke)

The Patient

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The Patient

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The Patient:

History of Present Illness:

Past Medical/Surgical History:

Hence the doctor ordered the following (ER LEVEL)

 Repeat Na in AM’s extraction

DOCTOR’S ORDER SHEET

NIHSS score: 0-5 (Mild Stroke)

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