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Admission date and time: 8/2/12 8:15:00pm Room no.

. 318 to ICU to 203-1 Room type: ward Last name: Leyesa First name: Paulino Middle name: Caiga Address: Purok 1 Tipakan Lipa City, Batangas Birth date: 6/18/1945 Birth place: Tiaong, Quezon Age: 67Y/1M/25D Sex: Male

Civil status: Married Religion: Catholic Citizenship: Filipino Occupation: None Relative: Elizabeth Del Rio Relationship: Daughter Attending Physicians: Dra. Ma. Lovely Cacho

Admission Diagnosis: CVA infarcts L periventricular frontal lobe / coronary artery disease / HPN

Final Diagnosis: CVA, multiple infarcts of R sided weakness coronary artery disease / HPN

Laboratory
August 3, 2012 Echo- Doppler Report Color Doppler Study: Normal left ventricular filling pattern Mitral regurgitation, mild (eccentric jet.)

Date: August 9, 2012 Examination: Cranial CT Scan Clinical History: CVA Technique: Multiple cranial CT slices are obtained without contrast using the standard departmental protocol. Findings: Previous plain cranial CT images dated 08/03/2012 are available for comparison. Interval findings of hypodense foci in the left periventricular frontal lobe, left coronaradiata and left centrum semiovale are now noted.

The well defined hypodense focus in the left centrum semiovale remains unchanged. The small ill-defined hypodensities in the left thalamus and both lentiform nuclei show no significant interval change. III-circumscribed hypodensities are again appreciated in the bilateral periventricular regions and semiovale centers. No demonstrable subarachnoid hemorrhage, intracerebral, subdural or epidural hematoma. The gray-white matter interface is maintained. There is no midline shift.

The ventricles, cisterns, sulci, including the extra axial spaces in the posterior fossa are prominent. The basilar, vertebral and internal carotid arteries are atherosclerotic. The visualized cerebellar hemispheres, pons, pineal region, orbits, paranasal sinuses, petromastoids and bony calvaria are intact.

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Impression: Acute infarcts in the left ventricular frontal lobe, left corona radiata and left centrum semiovale. Age- indeterminate infarcts, left thalamus and both lentiform nuclei, unchanged since 08/03/2012. Old infarct, left centrum semiovale. Chronic small vessel ischemic changes or areas of demyelization, periventricular regions and semiovale centers. Cerebro- cerebellar atrophy.

CT Scan Report History: CVA Findings: Plain CT Scan of the brain shows the following: Small-ill- defined hypodensity is appreciated in the left thalamus and both lentiform nuclei. In homogeneous decrease densities are appreciated in the periventricular regions and semiovale centers. No acute intracranial hemorrhage is detected. No discrete focal mass noted.

Midline structures are in place. The ventricles, cisterns and sulci are prominent including the extra axial spaces in the posterior fossa. The cavernous sinus and sella are unremarkable. The internal carotid arteries are calcified. The brainstem and cerebellum show no abnormal density change. The bony calvarium is intact. The paranasal sinuses, mastoids and orbits are unremarkable.

Impression: 1. No acute intracranial hemorrhage. 2. Small recent infarcts, left thalamus and both lentiform nuclei. 3. Chronic small vessel ischemic changes or areas of demyelization, periventricular regions and semiovale centers. 4. Cerebro- cerebellar atrophy. 5. Atherosclerotic vessel disease.

Radiographic Report: Impression: Moderate cardiomegaly with left ventricular prominence theromatous aorta.

Clinical Microscopy: Normal

Date: 08/1/2012 Chem 8: Glucose Cholesterol Triglyceride HDL LDL Uric acid Creatinine Date: 08/03/2012 Creatinine

Normal Normal Normal Normal Normal Normal Abnormal

116.9 188.8 167.4 47 118.4 5.9 1.8 1.29

Serum electrolytes Specimen: serum

Sodium Potassium Chloride

Result 142.7 4.02 103.8

Normal Normal Normal

RBS/ CBG Specimen: wholeblood Time collected at 8am Result: 84mg / dl

12LECG -normal sinus rhythm; within normal limits.

Date: 8/2/12 Hematology:

Hemoglobin Hematocrit WBC RBC Platelet count Segmenters Lymphocyte Monocyte MCV MCH MCHC RDW Result 12.3 36.4 8,500 3.96 232,000 0.68 0.26 0.06 92.0 31.1 33.8 13.7 Normal Normal Normal Abnormal Normal Abnormal Normal Normal Normal Normal Normal Normal

Date: 8/16/12 Hematology:

Hemoglobin Hematocrit WBC RBC Platelet count Segmenters Lymphocyte Monocyte MCV MCH MCHC RDW Result 11.5 34.5 11,400 3.87 419,000 0.78 0.16 0.06 89.1 29.7 33.3 12.4 Abnormal Abnormal Abnormal Abnormal Normal Abnormal Abnormal Abnormal Normal Normal Normal Normal

Neuro Logic Evaluation Sheet Best Motor Response To verbal command 6 To pain ful stimuli 5 Localizes pain 4 Decorticate Rigidity 3 Decerebrate Rigidity 2 No response 1

Best Verbal Response

Oriented and Converses 5 Disoriented and Converses 4 Inappropriate Words 3 Incomprehensive Words 2 No Response 1

Eye

Spontaneously 4

Opening

To verbal command 3

To pain 2

No response 1

From 7 pm to 2 am the total of Glasgow comma skill are 11 on August 8, 2012. From 7 pm to 7 am the total of Glasgow comma skill are 15 on August 12, 2012. 8 pm the total of Glasgow comma are 15, 8 pm the total of Glasgow comma is 13 from 9 pm to 3 am the total of Glasgow comma are 15.

Chief complaints: Slurred speech and body weakness History of present Illness 5 days PTA- (+) fever x 1 day (+) cough/ colds. (+) body weakness, (+) headache 3 days PTA- sought consult, given levofloxacin, fluimucil and losartin. 4 hours PTA- still with body weakness, was noted with secured speech, facial assymetry and occasionally incoherentadmitted.

Past Medical History: HPN (hypertension) Family History: None Review of system: Body malaise Fever Headache Poor appetite Numbness Impression: Hypertension- poorly controlled T/ C TIA T/ C Pneumonia.