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MANILA DOCTORS HOSPITAL

DEPARTMENT OF INTERNAL MEDICINE


667 United Nations Avenue
1000 Manila, Philippines

Grand rounds

Seafarers Wife

Attending Physicians:
Dr Chua

Dr Bacolcol

Reactors
Dr M Astejada

Dr D Roman

Dr C Dioquino

Dr S Salvana

Presented by: Olivia Faye J. Listanco, M.D.


Medical Resident Yr Level I

CASE PROTOCOL

Objectives:
1) To present a case of
2) To discuss

This is a case of COV, 46/F from Tagytay City, Cavite married, Roman
Catholic, working as a fitness instructor. She was admitted in Manila Doctors
Hospital on April 4, 2015.

Chief Complaint: Unsteady gait


The patient was allegedly well until
Three months PTA, noted weakness on the right arm described as inability to
carry her child. No reported trauma. Patient then sought consult at local hospital
and work up done included cervical neck CT scan. Patient then claimed she was
diagnosed with brachial plexus palsy. Patient then underwent rehabilitation therapy
for 3 sessions and reported improvement in the grip strength.
One week PTA, patient then had light headedness associated with unsteady
gait and tendency to fall. No reported weakness, slurring of speech, or headache.
During the interim symptoms persisted.
Three days PTA, patient sought consult at Tagaytay Hospital and was then
subsequently admitted. Patient claimed that the laboratory tests done yielded
normal results. She was then advised cranial CT scan hence transfer to MDH.
Past Medical History: (-)Hypertension, (-)Diabetes, (-)Bronchial asthma,
(-)Allergies, (-)previous PTB treatment; (-)previous surgeries; (-)known head trauma,
(+) treated for oral thrush and generalised skin dermatitis last January 2015

Personal/Social history:
Married to a Mexican national who works as sea man
Fond of eating raw fish and sea food in the Philippines and at Mexico
Non smoker
Occasional alcohol beverage drinking; no known binge-drinking episodes; no known
illicit drug use
Claimed 2 sexual partners (first (deceased) and second husbands)
Used to work in Africa 8 months and 10 years ago, and has frequent travels
between Philippines and Mexico
Family History:
(+) T2DM - mother
(-) hypertension, (-)cerebrovascular accidents, (-)cardiac disease
ROS:
(-)fever
(-)behavioral changes
(-) anorexia
(-)chestpain
(+) Anorexia since last January with unqualified weight loss
(ER Resident):
BP: 110/70 HR: 80
RR: 20
Clear breath sounds, distinct heart sounds
GCS 15
Patient was then referred to IM

Temp: 36.8

(ER IM ROD):
Physical Exam:
BP: 120/70 HR: 80
RR: 20
Temp: 36.5
GCS15
Non labored breathing
Pink conjunctivae, anicteric sclera. (-)CLAD
No retractions, equal chest expansion; Clear breath sounds
Adynamic precordium, distinct heart sounds, no murmurs appreciated
Abdomen flat, normoactive bowel sounds, nontender, no evident masses palpable
No gross joint deformities; no gross skin lesions
Full and equal peripheral pulses; no edema
Skin warm, dry
Neurological Exam:
MSE:
Frontal: Awake, alert, coherent, intact speech
Parietal: No R-L disorientation, (-) finger agnosia, (-) Acalculia
Temporal: Intact recent, remote, and immediate memory, oriented to 3
spheres
Occipital: Able to recognize familiar objects

Cranial nerves
CNI: intact
CNII: both pupils 2mm briskly reactive to light, visual field intact, fundoscopy not
done
CNIII, IV, VI: primary gaze at midline, full EOMs
CNV: intact V1-3, good masseter tone
CNVII: no facial asymmetry
CNVIII: intact gross hearing
CNIX, X: good gag, uvula at midline
CNXI: Good shoulder shrug and SCM tone
CNXII: tongue at midline
Motor: 5/5 on bilateral lower extremities, 3-4/5 on right upper, and 5/5 on left upper
Sensory: 100% on all extremities
DTR: 2+ on all
Cerebellar: No dysmetria, dysdiadokinesia
Posterior Column: unsteady gait, tendency to fall on either side, Romberg not done
Neck supple
(-) Babinski (-) Clonus
Laboratory tests done included CBC, BUN, creatinine, lipid profile, FBS, and SGPT.
Electrolytes were done outside. Cranial MRI with contrast and 12 lead ECG were
requested.
Primary working impression: D7 Cerebellar infarct, R/O Cerebellar mass;
brachial nerve palsy
Course of Admission:
1st Hospital Day:
S: Patient admitted at the floors managed as a case of cerebellar infarct. No reports
of headache or slurring of speech noted.
O: Patient had stable vital signs but still presented with 4/5 muscle strength on right
arm and 5/5 on rest of the extremities. Intact sensation on all extremities were
reported.

P: Initially put in complete bed rest without bathroom privileges, and diet started
was DAT. Medications started included Citicholine 1g IV q12, Vitamin B complex tab
BID, Betahistine 16mg OD, Pregabalin 75mg OD, and Atorvastatin 20mg ODHS.
Patient was seen by the Neurology AP, cranial MRI was ordered with emphasis on
the cerebellum and craniovertebral junction. ESR and VDRL were also requested.
Betahistine was increased to BID and Methylcobal 1 tab TID was started.
A: D7 Cerebellar infarct, R/O Cerebellar mass; brachial nerve palsy
2nd HD:

S: Patient had one episode of twitching of the right upper extremity lasting for less
than 3 minutes. No associated loss of consciousness. After the seizure patient had
stable VS.
O: Patient was seen after the seizure, assessed as to be awake, and oriented.
Patient was noted to have shallow left nasolabial fold and tongue deviation to the
left. Vital signs remained to be stable.
P: Patient was put into seizure precaution. Started on Leviteracetam 500mg/tab BID
and diazepam 5mg/IV PRN for frank seizure. Also, EEG was requested.
A: T/C Seizure disorder probably post-ictal, T/C Subacute infarct, probably right
capsuloganglionic versus posterior circulation; Brachial nerve palsy, T/C Stroke in
the Young

3rd HD:
S: Patient had no recurrence of seizure.
O: VS remained to be stable and neurologic deficits were unchanged.
Cranial MRI preliminary results revealed two granulomatous lesions left occipital and
right parietal with surrounding vasogenic edema.
Neurology AP the started the patient on Dexamethasone 5mg IV Q8 and
Leviteracetam was continued. Patient was then referred to The IDS service for comanagement.
A: Intracranial mass probable sec to Opportunistic infection, R/O Herniation
syndrome R/O HIV infection
4th HD
S/O: VS was stable and was in neuro status quo.
P: IDS service requested for code 174 test and CXR, TPHA (quantitative),
Toxoplasma IgG and IgM, PPD were requested. Patient was also started on
Ceftriaxone 2gm IV Q12 and Metronidazole 500mg IV Q6.
A: Intracranial mass probably secondary to infection 1. Abscess, 2. Toxoplasma, 3.
Syphilis, 4. Tuberculoma; R/O Herniation syndrome

6th HD:
S/O: VS was stable and was in neuro status quo.
P: EEG results showed intermittent slowing of background activity over frontal
region suggestive of focal pathology over the said region. Leviteracetam was
continued. Chest xray revealed no active infiltrates or lesion, hence AFB smear was
deferred.

A: Intracranial mass probably secondary to infection 1. Abscess, 2. Toxoplasma, 3.


Syphilis, 4. Tuberculoma; R/O Herniation syndrome

7th HD:
S/O: VS was stable and was in neuro status quo.
P: Patient tested for Toxoplasma IgM negative, IgG positive, and TPH was positive up
to 1:1280 dilutions. Patient was the treated for Toxoplasma infection and syphilis
infection. Antibacterial on board included Ceftriaxone 2gm IV Q12, Metronidazole
500mg IV Q6, and SMX TMP 800/60 BID to be completed for 4 weeks.
8th HD:
S/O: VS was stable and was in neuro status quo.
P: CALAS, CD4 and CD8 counts were requested. Dexamathasone was reduced to
5mg IV Q12 and the rest of the antibacterial were continued. Rehabilitation therapy
was also started.

9th HD:
S/O: VS was stable and was in neuro status quo.
P: Patient was referred to the ophthalmology service for fundoscopy regarding CMV
retinitis and toxoplasma retinitis but family opted to have the tests done as
outpatient. CNMS was also on bard for the nutritional build-up of the patient.

10th HD:
S/O: VS was stable and was in neuro status quo.
P: Patient presented with whitish plaques in the oral mucosa and was started on
Fluconazole 150mg TID. Repeat CT scan with contrast was also requested. Patient at
this time was on her Day 8 of Ceftriazone, Day 7 of Metronidazole and TXM SMP.
Dexamethasone was also shifted to Dexamethasone 4mg/tab BID.
Patient was cleared for possible discharge.
12th HD:
S/O: VS was stable and was in neuro status quo.
P: Initial CD4 count came out as 49 and CD8 count at 422. Patients partner was
advised code 174 workup. Patient completed 10 days of ceftriaxone and
metronidazole. Patient was cleared for possible discharge. IDS take home meds
included TMX SMP 800/160mg 1 tab BID to complete for 1 month, Azithromycin
500mg/tab 2 tab once a week, and Isoniazid 400mg/ tab OD x 6months. Patient
was advised follow up. Nuero home meds included Leviteracetam 500mg BOD and

gabapentin 75mg OD. Patient was then discharged apparently with improved
conditions.