Transcript Neurologic Examination

History
General Data
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33/F
G4P2 (2012)
Roman Catholic
From Quezon City
Admitted: August 13, 2009
• CC: L breast mass
History of Present Illness
11 months PTA:
- ~2x2cm breast mass, (L)
- (+) slight tenderness
- (-) accompanying skin changes/nipple
discharge/weight loss
- (-) consults done/medications taken
History of Present Illness
8 months PTA:
- (+) gradual enlargement of mass
- consult at a local hospital
- CNB: results showed fibrocystic changes
- No medications/interventions
- advised observation.
History of Present Illness
1 month PTA:
- Mass continued to enlarge; noted to triple
in size
- (+) nipple retraction
- consult at BCC
- Slide review of previous CNB slide:
invasive ductal CA
History of Present Illness
1 month PTA:
- (+) missed menses for 4 weeks
- (-) nausea/vomiting
- (+) slight dizziness
- pregnancy test: positive
- (-) consults / medications
Review of Systems
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(-) fever
(-) weight loss
(-) rashes
(-) headache/dizziness
(-) nasal discharge
(-) difficulty of breathing / dyspnea
(-) chest pain
(-) urinary complaints
(-) bowel disturbance
Past Medical History
• (-) DM / HPN / PTB / allergies / asthma
• No comorbidities
Family Medical History
• (-) CA, breast mass
• (-) Hypertension, DM, asthma, thyroid
disorder, epilepsy
Menstrual History
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Menarche: 12 yrs. Old
interval of 30 days
lasting for 3-5 days
consumes 3 pads per day, fully soaked
(-) dysmenorrhea
LMP: May 23, 2009
Sexual History
• First coitus 26 y/o (current partner,
nonpromiscuous)
• (-) dyspareunia
• (-) post coital bleeding
• (-) family planning method
Obstetric History
G
Year
AOG
Via
c/o
FMC
1
2001
FT
SVD
Tondo
General
(-)
2
2004
FT
SVD
Fabella
(-)
3
2008; abortion c/o hilot
4
2009; abortion
Personal/Social History
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housewife
Non-smoker
Non-alcoholic beverage drinker
Denies illicit drug use
Physical Examination
Physical Examination
• Conscious, coherent, ambulates with
assistance, not in cardiorespiratory
distress
• Vitals: BP 120/80 HR 82 RR 20 T 36.8
Physical Examination
HEENT:
• Pink palpebral conjunctivae, anicteric
sclerae, pupils ERTL
• Supple neck, no palpable cervical lymph
nodes, Thyroid gland not enlarged
Physical Examination
Chest/Lungs:
No retractions, Symmetrical chest
expansion, clear breath sounds
CVS:
Adynamic precordium, AB at 5th LICS MCL,
no murmur
Physical Examination
Abdomen:
Globular, NABS
Skin/Extremities:
• Warm, moist skin, no active dermatosis
• Full and equal pulses, no clubbing or
cyanosis of extremities, no edema
Physical Examination
Breast
• 10x10 cm mass- hard, slightly tender, non
movable mass L breast,
• (+) nipple retraction
• (-) skin changes/nipple discharge
• Essentially normal R breast
• (-) palpable axillary/cervical nodes
Physical Examination
Genitourinary:
• Normal external genitalia, no vaginal
discharge, no external lesion
• Internal Examination: Cervix- soft, long,
closed; Uterus- enlarged to approximately
12 weeks, no adnexal mass/tenderness
Physical Examination
Neurologic Examination
• Awake, alert, oriented to 3 spheres
• pupils 2-3 mm ERTL, no visual field cuts, (+)
ROR – OU
• full and equal EOM’s, V1-3 intact, can clench
teeth, Can smile, can raise eyebrows, can
close both eyes, no asymmetry, Intact gross
hearing, no lateralization on Weber’s, AC >
BC on Rinne, tongue midline on protrusion,
can raise shoulders
Physical Examination
Neurologic Examination
• - Motor: (-) spasticity, rigidity, fasciculation,
MMT 5/5 on all extremities
• ++ DTR’s on all extremities
• (-) sensory deficit
• (-) Babinski, (-) nuchal rigidity
Course in the Wards
Course in the Wards
• 8/13/09 (1st hospital day)
– Admitted to W4B29
• 8/14/09 (2nd hospital day)
– Referred to OB-GYN
Course in the Wards
• 8/15/09 (3rd hospital day)
– OB-Gyn: TV-UTZ done, showing early fetal
demise; suggest cervical ripening with
laminaria x 24h then reassessment of cervix.
– presented with possibility of D&C after MRM
if Sx is amenable
Course in the Wards
• 8/16/09 (4th hospital day)
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GS1: Noted OB entries
For OR scheduling: MRM, L
NPO
IVF: D5NR 1L x 8h
Cefazolin 1g IV LD ( ) ANST to be given at OR
OB may do D&C or insert laminaria
Anesthesiology: plan – GETA
pre-op meds – nalbuphine 5mg + promethazine
25mg as cocktail
Course in the Wards
• 8/16/09 (4th hospital day)
– OB-Gyn: will do D&C after MRM
– Anesthesiology: plan – GETA
– pre-op meds – nalbuphine 5mg +
promethazine 25mg as cocktail
– IVF: D5NR x 8h + K50 ext tubing on RUE (IV
Cannula g18)
Laboratory Examinations
Laboratory Examinations
• Blood Type: A+
• CBC Hgb 122, Hct 0.394, WBC 9.78, RBC
4.33, Plt 302, N 0.660, L 0.272
• PT 12.9/12.4/0.98/1.19
• aPTT 36.9/33.0
• BUN 2.68, Crea 50(L), Na 140, K 3.7, Cl
104
Ethical Considerations
Ethical Considerations
• 1st Trimester
– MRM (procedure of choice), in spite of increased
risk spontaneous abortion following anesthesia
– Chemotherapy - 12% risk of birth defects and risk
for spontaneous abortion
• 2nd Trimester
– MRM (procedure of choice)
– Chemotherapy – no evidence of teratogenicity
Ethical Considerations
• 3rd Trimester
– Lumpectomy with axillary node dissection if
adjuvent radiation therapy if deferred until
delivery
– Chemotherapy: no evidence of teratogenicity
• Prognosis is similar, stage by stage, to that of
nonpregnant Breast CA patients
Ethical Considerations
• Upon questioning, the patient was willing to
undergo chemotherapy and surgery in spite of
the risk of spontaneous abortion to the fetus
• According to her and her family, it is more
important to have her cured
• She finds herself unable to continue the
pregnancy if she still has cancer
Ethical Considerations
• Philippine Constitution Article 2, Sec 12:
– The State recognizes the sanctity of family life and
shall protect and strengthen the family as a basic
autonomous social institution. It shall equally
protect the life of the mother and the life of the
unborn from conception. The natural and primary
right and duty of parents in the rearing of the
youth for civic efficiency and the development of
moral character shall receive the support of the
Government.
Ethical Considerations
• Grounds on which abortion is permitted in the
Philippines:
– To save the life of a woman YES
– To preserve physical health NO
– To preserve mental health NO
– Rape/incest
NO
– Fetal impairment
NO
– Economic/social reasons
NO
– Available on request
NO
Ethical Considerations
• Authorization of an abortion requires
consultation with a panel of professionals
Source
• Brunicardi,et. Al. (2005). Schwartz’s Principles
of Surgery. 8th Ed. McGraw-Hill, USA.
• Philippine Constitution
• UN Abortion Policies: A Global Review (2002)
http://www.un.org/esa/population/publicatio
ns/abortion/profiles.htm. accessed on
8/17/09