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A Case of a man with relentless headache. Calma * Capili * Dagang * Dayrit. General Data. FV 49/M Married, Roman Catholic, from Canlubang Laguna Admitted to the PGH ER last April 2, 2010. Chief Complaint. Headache for 5 months. History of Present Illness. - PowerPoint PPT Presentation
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A Case of a man with relentless headache
Calma * Capili * Dagang * Dayrit
General DataFV49/MMarried, Roman Catholic, from
Canlubang LagunaAdmitted to the PGH ER last April 2,
2010
Chief ComplaintHeadache for 5 months
History of Present Illness
History of Present Illness
(+) weight loss (25% in 5 months)
(-) anorexia(-) fever(-) cough, colds(-) difficulty of
breathing(-) chest pain
Review of Systems(-) abdominal pain(+) 3 P’s(-) bowel complaints(-) seizures(-) loss of
consciousness(-) edema
Past Medical History(+) HPN – since 2000, UBP 160/100,
HBP 180/120, (-) maintenance medications
(+) DM – since 2003, (-) maintenance medications
(-) PTB, BA, allergies, history or trauma, previous surgeries
Family Medical History(+) HPN – father(-) DM, PTB, BA, CA
Personal Social HistoryTruck driver, married with 6 childrenNon-smoker, occasional alcoholic
beverage drinker, (-) illicit drug use
Physical ExaminationBP 130/90 HR 90 RR 20PC, AS, (-) CLAD, (-) ANMECE, CBS, (-)crackles/wheezes(-) heaves/thrills, DHS, NRRR, AB 5th
ICS LAAL, (-) murmursAbdomen flat, NABS, soft, non-tenderFEP, PNB, (-) clubbing, (-) edema
Neurologic ExaminationGCS 15, alert, awake, oriented to 3
spheresCranial NervesI Not assessed
II Pupils 3 mm EBRTL, VA: OD 20/40, OS 20-40-2, (-) visual field cuts
III, IV, VI
(+) LR palsy OS
V V1: R 100% L 10%; V2: R 100% L 10%; V3: B 100%
VII Shallow L NLF, (+) L central facial palsy VIII Webber: Lateralized to the L, Rinne: AS:
BC>ACIX, X Good gagXI Good shoulder shrugXII Tongue midline
Neurologic ExaminationMotor
Good muscle bulk, (-) spasticity, (-) flaccidity
5/5 5/5
5/5 5/5Sensory
100% 100%
100% 100%
Neurologic Examination DTRs
++ ++
++ ++
++ ++
Cerbellars: (-) dysmetria, (-) dystiadochokinesia Meningeals: (-) nuchal rigidity, (-) Kernig’s, (-) Brudzinski Autonomic
Cranial CT Scan(+) contrast enhancing tumor, ill
defined involving sellar-supresellar, sphenoidal areas
Cranial CT ScanInsert plates here
Cranial MRI with GAD(+) sellar-supresellar mass occupying
the sphenoid sinus as well(+) encasing B cavernous sinus with
invasion of clivusImpression: Chordoma vs. Invasive
Pituitary Adenoma
Cranial MRI with GADInsert plates here
Other Laboratory ExamsCBC: 4/2: Hgb 103 Hct 0.309 WBC
7.1 N 0.652 L 0.276 Plt 331PT/PTT: 4/2: 11.0/12.2/0.89/1.17;
32.6/37.34/5: FT4 8.4 (N 11-24 pmol/L), TSH
0.8 (N 0.3-3.8 mIU/L), Cortisol 25 (N 138-690 nmol/L), PRL 3,041.9 (80-430mIU/L)
Other Laboratory Exams
4/2 4/3 4/6 4/10 4/12 4/16 4/19Glucose 11.8 10.3
BUN 6.79 5.77 2.46
Crea 117 124 108
Na 127 127 126 126 119 115 132
K 4.1 4 4 4.1 4 3.4
Cl 88 90 90 85 72
Ca 2.23 1.97
Mg 0.68
Urine Na 238
Urine K 11.6
Urine Cl 213
Course in the ERIn the ER, pt managed primarily by
NSS, co-managed by ORL, Ophtha, and Endo
Pt GCS 15 while in the ER, no motor or sensory deficits.
Pt on the following medications: Mannitol 75 cc IV Q8 Q6, Celecoxib 200 mg/cap Q12, Tramadol 50 mg/tab TID Tramadol 50 mg IV Q8, Ketorolac drip (30 mg in 250cc D5W x 24h), Dexamethasone 5 mg/IV Q6
Course in the ERORL: A> hearing loss etiology to be
determined. Plan for PTA-ST and for transsphenoidal biopsy/GA once admitted
Ophtha: A> LR palsy probably secondary to malignancy. Refraction done. Plan for visual perimetry.
Course in the EREndo: A> Consider secondary hypogonadism,
secondary hypothyroidism, secondary hypoadrenalism secondary to suprasellar mass with mass effect. Hyperglycemia probably secondary to DM vs. steroid induced vs. combination. Hyponatremia secondary to SIADH due to tumor, secondary hypothyroidism, secondary to AI, secondary to mannitol use, orsecondary to hyperglycemia. Pt started on Levothyroxine 100 mcg/tab 30 min before breakfast, HN 20-0-10 SQ pre-melas, HR 8-8-8 SQ pre-meals, defer for CBG < 70mg/dL.