Date of Interview: July 18, 2013 History taken by: Informant: Patient

Source of Referral: None Percent Reliability: 90%

Identifying Data: Amado Gulay, Jr, 37 years old, male, has a live in partner, sewer, Filipino, Catholic, born in Guindulman, Bohol on May 10, 1976, presently residing at San Isidro, Cainta, Rizal admitted for the 1st time at FEU-NRMF Medical Center on June 8, 2013. Chief Complaint: Vomiting History of Present Illness: 1 day PTA, the patient is apparently well however he was unable to take his maintenance antihypertensive medicines such as amlodipine. 4 hours PTA, the patient was having a break from his work. While drinking cobra energy drink, he suddenly felt dizzy accompanied by excessive perspiration with noted cold clammy skin. He decided to take a rest but to no avail. No medications were taken. 3 hours PTA, still with the above signs and symptoms, but now accompanied by nausea and (projectile or non projectile?) vomiting, vomitus described as yellowish in color and measuring about a cup in volume. After a few minutes, he then experience loss of consciousness. The above condition persisted but with no accompanying signs and symptoms like headache, abdominal pain, sob, difficulty of breathing, chest pain, body weakness or slurred speech, hence his officemates decided to bring him at the FEU-NRMF Hospital and subsequently admitted.

Past Medical History: He had measles, mumps and chicken pox during childhood. His childhood immunizations were complete. In July 2008, he was admitted in a hospital on Lebanon due to mild stroke and hypertension with a highest BP of 160/80. He was discharged with left sided weakness. Maintained on aspirin, felodipine, and other drugs prescribed with unknown dosages. He has no regular medical check up and no history of previous operations, blood transfusion, accidents, injuries, allergy and psychiatric diseases. Family History: His father is 59 year-old, apparently well. His mother is 64 year-old with hypertension. He has 5 siblings, his brother has hypertension and one of his sister died because of cardiac problem exact diagnosis was unrecalled. He has 3 daughters all are apparently well. Personal and Social History: The patient has a live in partner for 7 years, his partner is apparently well. He works as a sewer for 10 years. He lives in a bungalow house, which is well ventilated with 2 windows, far from creeks and factories with regular waste segregation and disposal and constant supply of clean water from Maynilad. He is a chronic smoker with 12 pack-years. Alcoholic beverage drinker, he usually consumes an average of 2-3 bottles of beer weekly. He is fond of eating salty food, vegetables and pork. No regular exercise and drinks 1 cup of coffee per day. No history of STI and drug abuse.

Review of systems: Constitutional Symptoms: (-)weight loss (-)generalized body weakness, (-)fatigue, (-)loss of appetite.Skin: (-)itchiness on lower leg, (-)excessive dryness or sweating (-)change in colorHead: (-)dizziness (-)vertigo Eyes: (-)use of eyeglasses, (-)cataract, (-)pain, (-)blurring of vision, (-)double vision, (-)lacrimation, (-)photophobia Ears: (-)ear ache, (-)deafness, (- )tinnitus (-)ear discharge.Nose: (-)changes in smell, ()nose bleeding (-)nose obstruction, (-)nasal discharge, (-) pain over sinuses. Mouth and Throat: (-)toothache, (-)gum bleeding, (-)disturbance in taste, (-)sore throat, (-)hoarseness Neck: (-)pain, (-)limitation of movement, (-)presence of mass.Breast: (-)pain, (-)lumps, ()nipple discharge. Respiratory:(-)difficulty of breathing, (-)cough, (-)sputum production, (-)hemoptysis, ()wheezes. Cardiavascular: (-)substernal pain, (+)palpitations, (-)orthopnea, (-)syncope (-)easy fatiguability Gastrointestinal: (-)nausea and vomiting, (-)abdominal pain (-)dysphagia, (-)diarrhea, (-)constipation, (-)melena, (-)hematemesis.Genitourinary: (-)urethral discharge, ()incontinence

PHYSICAL EXAMINATION: General Survey: Patient is conscious, coherent, afebrile; oriented to place, person and time; looks appropriate for her age, well-kempt, fluent, not in cardio-respiratory distress; with the following vital signs: BP: 130/90 mm Hg CR: 82 bpm RR: 20 cpm Temp: 36.2oC Skin: Brown complexion, normal degree of moisture, normal elasticity, mobility and thickness; black, shoulder length hair of normal quantity and even distribution; pink nail beds, nail plates are smooth, no lesion; nail folds normal, Several hyperpigmented macules in the lower extremities. Head: Hair is thick, black, evenly distributed, normocephalic, no masses, no lesions, nor tenderness, left temporal artery is visible, with strong equal pulses and walls are soft and not thickened. Face: Round, symmetrical, skin is brown, normal facie, no masses; no involuntary movements. Eyes: Eyebrows are black, thin, evenly distributed, no erythema, no ptosis, and no lesions noted; palpebral fissures are symmetrical; normally set eyeballs, thick eyelashes,

with outward direction of growth, no matting; pink palpebral conjunctiva, anicteric sclerae, transparent cornea, no lesions no scar; lens are clear on both the left and right eye, black iris with regular contour; pupils are equally round, right pupil is non-reactive to light and accommodation. Fundoscopic examination reveals positive red orange reflex on both right and left eye, 2:3 AV ratio, distinct optic disc and no hemorrhages. Ears: Auricles are symmetrical and non-tender; auditory canals are patent, has no discharge, walls are pink without lesions, tympanic membranes are pearly white, intact, normal contour, with visible cone of light. No perforations. Nose: Nose is symmetrical, no flaring of ala nasi, no deformity, patent vestibules, mucosa is hyperemic, septum in midline and intact, no nasal discharge. No tenderness over the frontal and maxillary sinuses. (+) transillumination test Mouth and Oral Cavity: Lips are pink, moist, symmetrical, with reddish crusts on upper lip; buccal mucosa and gums are pink and moist, smooth, no signs of swelling. Gums are pinkish, no swelling. Complete set of teeth, no dental caries. Tongue is at midline. Hard and soft palate are pinkish, no lesions; uvula is at midline, tonsils are not enlarged; pharyngeal wall is pinkish, no exudates. Neck: Neck is normal in size, supple, symmetrical, no neck vein engorgement, no mass, normal muscle development and tone, trachea in midline; lymph nodes not palpable, thyroid gland not palpable. No carotid bruit noted. Lungs/chest: Skin is brown, no dilated superficial blood vessels, bony thorax is elliptical, symmetrical without gross deformities; no tenderness, symmetrical lung expansion, with effortless breathing, no retraction, normal and equal tactile fremitus on both sides anteriorly, posteriorly and laterally. Entire lung area is resonant with vesicular breath sounds. No adventitious breath sound, no bronchoscopy, no egophony and no whispered pectoriloquy. Cardiovascular: Adynamic precordium, apex beat is at the 5th intercostal space left midclavicular line. No heaves. No thrills. Regular rhythm, normal S1 and S2. No adventitious heart sounds were appreciated. No murmur. Abdomen: skin is brown, flat, inverted umbilicus, no visible mass, no superficial dilated blood vessels, no abnormal pulsations, no bulging flanks. Normoactive bowel sound, no bruit on the epigastric and paraumbilical areas, no tenderness noted. Negative fluid wave and shifting dullness. Liver span is 8cm. abdomen is soft without superficial masses or tenderness. On deep palpation, the spleen and kidneys are non-palpable, with rounded liver edge and no rebound tenderness, nor masses. No costovertebral angle tenderness. NEUROLOGIC EXAMINATION: Cerebrum: Patient is conscious, coherent, oriented to place, time and person, with a GCS of 15/15 (E4V5M6), intact recent, immediate and remote memory. Language is fluent, able to repeat a series of digits and able to follow verbal commands. Cerebellum: can do finger-to-nose test and rapid alternating movements. Cranial nerves CN I: able to identify smell of coffee

CN II: 3-4 mm pupils; right pupil non-reactive to light and accommodation; 20/20 left eye; 20/50 right eye CN III, IV, & VI: equal and complete opening of both eyes; intact extraocular muscles CN V: can feel pain and light touch on both sides of the face; CN VII: can perform facial expressions; no facial asymmetry CN VIII: able to hear clearly, no nystagmus CN IX & X: uvula at midline, equal elevation of palate on phonation CN XI: can turn head from side to side, can elevate shoulders CN XII: tongue midline, mobile, no atrophy nor fasciculation

MOTOR SENSORY REFLEX No atrophy, no fasciculations, no involuntary movements, normal muscle tone on all extremities. MOTOR 5/5 5/5 5/5 5/5 100% 100% SENSORY 100% 100%

MUSCULOSKELETAL EXAMINATION: Superficial reflexes: Abdominal reflexes absent Deep tendon reflexes: biceps ++ ; brachioradialis ++ ; triceps ++ ; knee jerk ++ ; ankle jerk ++ Release reflexes: snout reflex absent, grasp reflex - absent Pathologic reflexes: (-) Babinski, (-) ankle clonus Signs of meningeal irritation: (-) Nuchal rigidity, (-) Brudzinski DIAGNOSIS: Intracerebral Hemorrhage Right, secondary to increase ICP secondary to hypertension DIFFERENTIAL DIAGNOSIS:

PATHOPHYSIOLOGY:

Laboratory Work-up: Neuroimaging such as CT Scan or MRI and bedside glucose measurement are necessary and must be requested to distinguish intracerebral hemorrhage from ischemic stroke, subarachnoid hemorrhage, and other causes of acute neurologic deficits (eg, seizure, hypoglycemia). Neuroimaging is usually diagnostic. If neuroimaging shows no hemorrhage but subarachnoid hemorrhage is suspected clinically, lumbar puncture is necessary. Treatment: Treatment includes supportive measures and control of general medical risk factors. Anticoagulants and antiplatelet drugs are contraindicated. Hypertension should be treated only if mean arterial pressure is > 130 mm Hg or systolic BP is > 185 mm Hg. Nicardipine 2.5 mg/h IV is given initially; dose is increased by 2.5 mg/h q 5 min to a maximum of 15 mg/h as needed to decrease systolic BP by 10 to 15%. Early evacuation of large lobar cerebral hematomas may also be lifesaving, but re-bleeding occurs frequently, sometimes increasing neurologic deficits. Early evacuation of deep cerebral hematomas is seldom indicated because surgical mortality is high and neurologic deficits are usually severe.