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GCP-SECTION-12

Grand case Presentation

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Apple Mae Virtudazo
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2 views

GCP-SECTION-12

Grand case Presentation

Uploaded by

Apple Mae Virtudazo
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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Room 320 #8418 Source: Pt and Sibling (sister)

Date of admission: August 23, 2024 @10:15 am

Pt: Ebal, Marie Jamodiong

Age: 42

Sex: F

Wt: 68kg Ht: 157.48 cm

Religion: IFI

Address: Purok 5, Pagawan, Manticao, Mis.Or.

Birthday: 11/03/1981

Occupation: Housekeeper

Allergies: NKA

Admitted via: wheelchair

CC: seizure

Admitting diagnosis: Intracranial Mass, Left mass: 4x5x6

Principal Diagnosis: Intracranial Tumor, Left Parietal Lobe; Focal Motor Seizure

Diet: DAT

Physician: Dr. Aldanica Olano

Upon Admission: HR-116bpm RR-28cpm Temp-36.4

Morning @9am (long duration seizure)

FEBRUARY MAY JUNE NOW


First seizure B complex Refer CT scan August 24: palpitate,
Leg lang numb Half body right side No SOB, normal urine
Admitted then Meds given/prescribed:
discharged  Levi(basta katong No heavy lifting??
Given B-complex antiseizure) No hard/heavy
 Laxative(lactulose) meats??
 Steroids(dexa)
 Ocassipnal
supplement
Current VS:

BP: 120/90 RR: 21 HR: 75 Temp: 36.4 02: 94%

Hx: Father: Hypertensive

Husband: smoking

Pt drinks alcohol occasionally

Assessment: No fever, no cough but last last week (+)cough

Chart: (-) edema and (+)cushichuchu fessie(di namo masabtan)

Special considerations: VS q 4hrs, maintain seizure prec, 02 sat >94

HPI: ako sa sabton ako handwriting (naa amn to audio hehe)

Omeprazole 40mg IV OD
Levetiracetam 500mg tab PO TID
Dexamethasone 40mg tab, ½ tab OD @ lunch
PCM 500mg 1 tab q 4hrs PRN
Calcium gluco AMP x1 (unsa ni?? Buang na)
Diazepam IVTT
3am #3 PNSS 20 gtts/min + 40 meqs to run for 12 hrs

LABS: August 23

CBC, U/A defer, 12L ECG, CREA, FBS, LP H(+), CXR PA-enroute

Blood chem

K: 3.17 meq/L LOW

Ca: 1.10 LOW

CBC Hct: 36.60 LOW

MCH 31.80 HIGH

Platelet 147 LOW

Neutrophils 82.4 H

Eosinophils 0.7 LOW


PROCALCITONIN 0.110 ug/L

PCT < 0.5 ug/L minor or no local inflammation/ infection possible

PCT 0.5-2.0 ug/L Dx of sepsis (+)

PCT 2.0-10 ug/L increase risk of developing organ dysfunction

PCT >10 ug/L frequent associated with organ dysfunction, increase risk of lethal outcome

ECG: sinus tachycardia >99

LIPID PROFILE:

FBS: 125.67 mg/dl H N: 70-99

Chole: 215.11 mgs/dl H N: <200

LDL: 154.90 N: <130

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