MANILA DOCTORS HOSPITALDEPARTMENT OF INTERNAL MEDICINE667 United Nations Avenue1000 Mania! P"ii##inesGrand rounds Seafarers WifeAttending Physicians: DrChuaDr BacolcolReactorsDr M AstejadaDr C DioquinoDr D RoanDr S Sal!ana Presented "y:#li!ia $aye %& 'istanco( M&D&Medical Resident )r 'e!el *CAS+ PR#,#C#'#"jecti!es:1) To present a case of2) To discuss This is a case of COV, 46/F from Tagytay City, Cavite married, oman Catho!ic, "or#ing as a $tness instructor% &he "as admitted in 'ani!a (octors )ospita! on *pri! 4, 2+1,% Chief Co-laint: -nsteady gaitThe patient "as a!!eged!y "e!! unti!.Three months /T*, noted "ea#ness on the right arm descri0ed as ina0i!ity to carry her chi!d% 1o reported trauma% /atient then sought consu!t at !oca! hospita! and "or# up done inc!uded cervica! nec# CT scan% /atient then c!aimed she "as diagnosed "ith 0rachia! p!e2us pa!sy% /atient then under"ent reha0i!itation therapy for 3 sessions and reported improvement in the grip strength% One "ee# /T*, patient then had !ight headedness associated "ith unsteady gait and tendency to fa!!% 1o reported "ea#ness, s!urring of speech, or headache% (uring the interim symptoms persisted% Three days /T*, patient sought consu!t at Tagaytay )ospita! and "as then su0se4uent!y admitted% /atient c!aimed that the !a0oratory tests done yie!ded norma! resu!ts% &he "as then advised crania! CT scan hence transfer to '()%Past Medical .istory: 56))ypertension, 56)(ia0etes, 56)7ronchia! asthma, 56)*!!ergies, 56)previous /T7 treatment8 56)previous surgeries8 56)#no"n head trauma, 59) treated for ora! thrush and genera!ised s#in dermatitis !ast :anuary 2+1,Personal/Social history:'arried to a 'e2ican nationa! "ho "or#s as sea manFond of eating ra" $sh and sea food in the /hi!ippines and at 'e2ico 1on smo#erOccasiona! a!coho! 0everage drin#ing8 no #no"n 0inge6drin#ing episodes8 no #no"n i!!icit drug useC!aimed 2 se2ua! partners 5$rst 5deceased) and second hus0ands)-sed to "or# in *frica ; months and 1+ years ago, and has fre4uent trave!s 0et"een /hi!ippines and 'e2ico$aily .istory:59) T2(' 6 mother56) hypertension, 56)cere0rovascu!ar accidents, 56)cardiac diseaseR#S:56)fever 56)0ehaviora! changes56) anore2ia56)chestpain59) *nore2ia since !ast :anuary "ith un4ua!i$ed "eight !oss0+R Resident1: 7/< 11+/=+ )< ;+ < 2+ Temp< 36%;C!ear 0reath sounds, distinct heart sounds>C& 1, /atient "as then referred to ?'0+R *M R#D1:Physical +2a: 7/< 12+/=+ )< ;+ < 2+ Temp< 36%,>C&1,1on !a0ored 0reathing/in# con@unctivae, anicteric sc!era% 56)CA*(1o retractions, e4ua! chest e2pansion8 C!ear 0reath sounds*dynamic precordium, distinct heart sounds, no murmurs appreciated*0domen Bat, normoactive 0o"e! sounds, nontender, no evident masses pa!pa0!e1o gross @oint deformities8 no gross s#in !esionsFu!! and e4ua! periphera! pu!ses8 no edemain "arm, dry1euro!ogica! C2amood shou!der shrug and &C' toneC1E??< tongue at mid!ine'otor< ,/, on 0i!atera! !o"er e2tremities, 364/, on right upper, and ,/, on !eft upper&ensory< 1++F on a!! e2tremities(T< 29 on a!!Cere0e!!ar< 1o dysmetria, dysdiado#inesia/osterior Co!umn< unsteady gait, tendency to fa!! on either side, om0erg not done 1ec# supp!e56) 7a0ins#i 56) C!onusAa0oratory tests done inc!uded C7C, 7-1, creatinine, !ipid pro$!e, F7&, and &>/T% C!ectro!ytes "ere done outside% Crania! '? "ith contrast and 12 !ead CC> "ere re4uested%Priary 3or4ing i-ression: (= Cere0e!!ar infarct, /O Cere0e!!ar mass8 0rachia! nerve pa!syCourse of Adission:5st .os-ital Day:&< /atient admitted at the Boors managed as a case of cere0e!!ar infarct% 1o reports of headache or s!urring of speech noted% O< /atient had sta0!e vita! signs 0ut sti!! presented "ith 4/, musc!e strength on rightarm and ,/, on rest of the e2tremities% ?ntact sensation on a!! e2tremities "ere reported% /< ?nitia!!y put in comp!ete 0ed rest "ithout 0athroom privi!eges, and diet started "as (*T% 'edications started inc!uded Citicho!ine 1g ?V 412, Vitamin 7 comp!e2 ta0 7?(, 7etahistine 16mg O(, /rega0a!in =,mg O(, and*torvastatin 2+mg O()&% /atient "as seen 0y the 1euro!ogy */, crania! '? "as ordered "ith emphasis on the cere0e!!um and cranioverte0ra! @unction% C& and V(A "ere a!so re4uested% 7etahistine "as increased to 7?( and 'ethy!co0a! 1 ta0 T?( "as started% *< (= Cere0e!!ar infarct, /O Cere0e!!ar mass8 0rachia! nerve pa!sy6nd .D:&< /atient had one episode of t"itching of the right upper e2tremity !asting for !ess than 3 minutes% 1o associated !oss of consciousness% *fter the seiDure patient had sta0!e V&% O< /atient "as seen after the seiDure, assessed as to 0e a"a#e, and oriented% /atient "as noted to have sha!!o" !eft naso!a0ia! fo!d and tongue deviation to the !eft% Vita! signs remained to 0e sta0!e% /< /atient "as put into seiDure precaution% &tarted on Aeviteracetam ,++mg/ta0 7?( and diaDepam ,mg/?V /1 for fran# seiDure% *!so, CC> "as re4uested% *< T/C &eiDure disorder pro0a0!y post6icta!, T/C &u0acute infarct, pro0a0!y right capsu!ogang!ionic versus posterior circu!ation8 7rachia! nerve pa!sy, T/C &tro#e in the Goung7rd .D:S: /atient had no recurrence of seiDure% #: V& remained to 0e sta0!e and neuro!ogic de$cits "ere unchanged% Crania! '? pre!iminary resu!ts revea!ed t"o granu!omatous !esions !eft occipita! andright parieta! "ith surrounding vasogenic edema% 1euro!ogy */ the started the patient on (e2amethasone ,mg ?V H; and Aeviteracetam "as continued% /atient "as then referred to The ?(& service for co6management% *< ?ntracrania! mass pro0a0!e sec to Opportunistic infection, /O )erniation syndrome /O )?V infection8th .D&/O< V& "as sta0!e and "as in neuro status 4uo% /< ?(& service re4uested for code 1=4 test and CE, T/)* 54uantitative), To2op!asma ?g> and ?g', //( "ere re4uested% /atient "as a!so started on Ceftria2one 2gm ?V H12 and 'etronidaDo!e ,++mg ?V H6% *< ?ntracrania! mass pro0a0!y secondary to infection 1% *0scess, 2% To2op!asma, 3% &yphi!is, 4% Tu0ercu!oma8 /O )erniation syndrome 9th .D: &/O< V& "as sta0!e and "as in neuro status 4uo% /< CC> resu!ts sho"ed intermittent s!o"ing of 0ac#ground activity over fronta! region suggestive of foca! patho!ogy over the said region% Aeviteracetam "as continued% Chest 2ray revea!ed no active in$!trates or !esion, hence *F7 smear "as deferred%*< ?ntracrania! mass pro0a0!y secondary to infection 1% *0scess, 2% To2op!asma, 3% &yphi!is, 4% Tu0ercu!oma8 /O )erniation syndrome :th .D:&/O< V& "as sta0!e and "as in neuro status 4uo% /< /atient tested for To2op!asma ?g' negative, ?g> positive, and T/) "as positive upto 1