A Case of a man with relentless headache

Calma * Capili * Dagang * Dayrit

General DataFV

49/M

Married, Roman Catholic, from Canlubang Laguna

Admitted 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 children

Non-smoker, occasional alcoholic beverage drinker, (-) illicit drug use

Physical ExaminationBP 130/90 HR 90 RR 20

PC, AS, (-) CLAD, (-) ANM

ECE, CBS, (-)crackles/wheezes

(-) heaves/thrills, DHS, NRRR, AB 5th ICS LAAL, (-) murmurs

Abdomen flat, NABS, soft, non-tender

FEP, PNB, (-) clubbing, (-) edema

Neurologic ExaminationGCS 15, alert, awake, oriented to 3

spheres

Cranial 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>AC

IX, X Good gag

XI Good shoulder shrug

XII Tongue midline

Neurologic ExaminationMotor

Good muscle bulk, (-) spasticity, (-) flaccidity

5/5 5/5

5/5 5/5

Sensory

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 clivus

Impression: 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 331

PT/PTT: 4/2: 11.0/12.2/0.89/1.17; 32.6/37.3

4/5: 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 4/19

Glucose 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.