Iloilo Doctors’ College of Medicine, Inc.

West Timawa, Molo, Iloilo City

DEPARTMENT OF SURGERY

SCC DE LA CALZADA, AIANA KATHRYNA S.

I. GENERAL DATA

This is the case of J.S., a 23 year-old male, Filipino, from Rizal Pala-Pala, Iloilo. This is his 1st admission at
Iloilo Doctors’ Hospital, seen and examined last July 25, 2023.

The primary Informant is the patient’s father with 95% reliability.

II. CHIEF COMPLAINT

Seizure

III.HISTORY OF PRESENT ILLNESS

5 years PTA, patient experienced loss of consciousness and was immediately brought to a public hospital.

CT scan was requested, and according to the informant, the finding was “may abnormal nga ugat sa right

nga parte sang ulo”, and was appraised by the attending physician to be managed with medications and

an unrecalled laser procedure which is not available in the locality. Patient did not comply to the suggested

management due to financial constraints.

1 year PTA, patient experienced intermittent headache described by the patient as “daw gina barina”, and

several seizure episodes which lasted for about 2-5 minutes per episode and aggravated by stress. Folks

claim to give ointments to induce sleep and reduce seizure attacks.

7 months PTA, intermittent headache and seizure episodes persisted. The patient sought consult at a

public hospital, CT Scan was requested and finding showed AV Malformation, R, Posterior Cerebral Artery
 Iloilo Doctors’ College of Medicine, Inc.
West Timawa, Molo, Iloilo City
DEPARTMENT OF SURGERY

SCC DE LA CALZADA, AIANA KATHRYNA S.

Territory, and was given Levetiracetam 500mg tab and Orphenadrine citrate Paracetamol 50mg/650mg

tab for maintenance. The patient claims to be compliant to medication.

1 month PTA, the folks noticed a change in the patient’s physique secondary to unintentional weight loss.

2 days PTA, the patient had intermittent headache with sudden loss of appetite, increased apathy and

lethargy.

On the day of admission, symptoms persisted, patient sought consult to a private physician, thus, this

case.

IV. PAST MEDICAL HISTORY

(-) Hypertension

(-) Diabetes Mellitus

(-) Food and Drug Allergies

(-) Surgical Procedure

V. FAMILY HISTORY

(+) DM, maternal

VI. PERSONAL-SOCIAL HISTORY

(+) Smoker; 0.45 pack years

(+) Occasional Alcoholic drinker

 Iloilo Doctors’ College of Medicine, Inc.
West Timawa, Molo, Iloilo City
DEPARTMENT OF SURGERY

SCC DE LA CALZADA, AIANA KATHRYNA S.

VII. PHYSICAL EXAMINATION

GENERAL SURVEY:

The patient was awake, lying in bed, lethargic, not oriented to time, place, and person; not in
cardiopulmonary distress. GCS 14 (E4, V4, M6).

VITAL SIGNS:

Results Normal Values Interpretation

Temperature 36.3℃ 36.5- 37.5 °C Normal

Heart Rate 88 bpm 60-100 beats/minute Normal

Respiratory Rate 22 cpm 14-20 cycles/minute Normal

Blood Pressure 90/70 mmHg <120/<80mmHg Decreased

Oxygen saturation 98% >95% Normal

VIII. ANTHROPOMETRIC DATA:

WEIGHT: 57
HEIGHT: 170.18 cm
BMI: 19.7
INTERPRETATION: NORMAL
 Iloilo Doctors’ College of Medicine, Inc.
West Timawa, Molo, Iloilo City
DEPARTMENT OF SURGERY

SCC DE LA CALZADA, AIANA KATHRYNA S.

IX. REVIEW OF SYSTEMS

A. INTEGUMENTARY:

Skin is warm with good skin turgor, capillary refill time of <2 seconds, no active skin lesions.

B. HEENT

Normocephalic head, anicteric sclerae, pinkish conjunctiva.

Pupils are equally round and (+) dilated, 4-5mm. (+) Sluggish pupillary reaction to light and
accommodation; (+) Blurry Vision, R eye;

Oral mucosa is pinkish, without lesions or ulcers.

No cervical lymphadenopathies.

C. CARDIOVASCULAR

Adynamic precordium, regular cardiac rate and regular rhythm.

PMI is at the 5th ICS intercostal space midclavicular line. No murmurs.

D. LUNGS

No chest lesions or deformities present, symmetrical chest expansion. Equal vocal and tactile fremitus.
Bronchovesicular breath sounds on all lung fields.

E. GASTROINTESTINAL

Inspection: Abdomen is flat. No scars, ulcers, prominent veins, striae, or masses seen.

Auscultation: Normoactive bowel sounds. 16 clicks/min.

Percussion: Tympanitic on all four quadrants.

Palpation: Abdomen is soft, non-tender.

 Iloilo Doctors’ College of Medicine, Inc.
West Timawa, Molo, Iloilo City
DEPARTMENT OF SURGERY

SCC DE LA CALZADA, AIANA KATHRYNA S.

F. EXTREMITIES

Upper extremities

Inspection: Skin is light brown. Upper extremities are asymmetrical secondary to poor nutrition. No
varicosities, ulcers, erythema, active scars and cyanosis noted.

Palpation: Skin was dry and warm. No edema and lumps noted. Brachial pulses were

grade 2+. Capillary refill time <2 secs.

Lower extremities

Inspection: Skin is light brown. No ulcers, erythema, varicosities, scars and edema
noted. Lower extremities are asymmetrical secondary to poor nutrition.
Palpation: Skin was dry and warm. No lumps or edema noted. Dorsalis pedis pulse was
graded 2+. Capillary refill time <2 secs.

X. ADMITTING IMPRESSION

Arteriovenous Malformation, Right, Posterior Cerebral Artery Territory

XI. SALIENT POINTS

(+) Seizure

(+) Intermittent Headache

(+) Unintentional Weight Loss

 Iloilo Doctors’ College of Medicine, Inc.
West Timawa, Molo, Iloilo City
DEPARTMENT OF SURGERY

SCC DE LA CALZADA, AIANA KATHRYNA S.

XII. DIAGNOSTIC FLOWSHEET

1. SARS-COV 2- RAPID ANTIGEN TEST – NEGATIVE

2. Clinical Chemistry

Test Result Normal Range

S Na 134 mmol/L 136-145

SK 4.29 mmol/L 3.5 - 5.1

S Creatinine 57.50 mmol/L 49 - 90

3. Complete Blood Count w/ Actual Platelet Count

Examination 7-25-2023 Reference Value

Hemoglobin 145 120-150

Hematocrit 0.41 0.35-0.49
RBC 4.94 3.8-5.2
WBC 9.60 4.5-11.0
MCV 82.90 80-100
IX.
MCH 29.30 26-34
MCHC 35.30 32-36

Differential count
Neutrophil 0.74 0.55-0.65
Eosinophil 0.01 0.02-0.04
Lymphocyte 0.20 0.25-0.35
Monocyte 0.04 0.03-0.06

Platelet N/A 170-400

THERAPEUTIC FLOWSHEET
 Iloilo Doctors’ College of Medicine, Inc.
West Timawa, Molo, Iloilo City
DEPARTMENT OF SURGERY

SCC DE LA CALZADA, AIANA KATHRYNA S.

Drug Mode of Action Indication
Levetiracetam Levetiracetam binds selectively to SV2A, Effective treatment of focal seizures
500 mg /tab a ubiquitous synaptic vesicle integral membrane in adults and children, primary
protein, which may function as a positive generalized tonic-clonic seizure, and
effector of synaptic vesicle exocytosis. Binding the myoclonic seizures of juvenile
SV2A in the vesicle reduces of the excitatory myoclonic epilepsy.
neurotransmitter glutamate during trains of
high-frequency activity.
Dexamethasone Steroids reduce inflammation and are Inflammatory Joint Diseases
4 mg/tab immunosuppressant. They cross the cell Shock
1 tab TID membrane and bind to a glucocorticoid Anti-
receptor. The complex moves into the cell inflammatory/immunosuppressive
nucleus, where it will both suppress and Cerebral Edema caused by
stimulate transcription. This leads to a reduction malignancy
in proinflammatory mediators such as
eosinophils, mast cells, macrophages,
interleukins and phospholipase A2. There is an
upregulation of anti-inflammatory mediators,
which ultimately reduces prostaglandin and
leukotriene synthesis.
Mannitol 150 Mannitol exerts its ICP-lowering effects via two Osmotic Diuretic; Reduction of raised
150 cc IV Q4H mechanisms—an immediate effect because of intracranial and intraocular Pressure
plasma expansion and a slightly delayed effect
related to its osmotic action. The early plasma
expansion reduces blood viscosity and this in
turn improves regional cerebral microvascular
flow and oxygenation. It also increases
intravascular volume and therefore cardiac
output. Together, these effects result in an
increase in regional cerebral blood flow and
 Iloilo Doctors’ College of Medicine, Inc.
West Timawa, Molo, Iloilo City
DEPARTMENT OF SURGERY

SCC DE LA CALZADA, AIANA KATHRYNA S.

compensatory cerebral vasoconstriction in brain
regions where autoregulation is intact, resulting
in a reduction in ICP. Cardiac output may
subsequently decrease to lower than baseline
levels because of the peripheral vasodilatation
induced by mannitol and care must be taken to
ensure that cerebral perfusion pressure is
maintained at this time. Mannitol also
establishes an osmotic gradient between plasma
and brain cells, drawing water from the cerebral
extracellular space into the vasculature, thereby
reducing cerebral oedema. An intact blood–
brain barrier (BBB) is a prerequisite for
mannitol's osmotic action and cerebral oedema
may be worsened by mannitol administration if
the BBB is disrupted.
Esomeprazole An s-isomer of omeprazole Gastro-esophageal Reflux Disease
40 mg IV Q8H A substituted benzimidazole proton pump Eradication of H. pylori associated
inhibitor (PPI) that blocks the final step in gastric peptic ulcer disease
acid secretion by specific inhibition of H+/K+- Zollinger-Ellison Syndrome
ATPase enzyme system present on the secretory NSAID-associated ulceration
surface of the gastric parietal cells.
 Iloilo Doctors’ College of Medicine, Inc.
West Timawa, Molo, Iloilo City
DEPARTMENT OF SURGERY

SCC DE LA CALZADA, AIANA KATHRYNA S.

XIII. CASE DISCUSSION

Arteriovenous Malformation

AVMs damage the brain or spinal cord through three basic mechanisms: by reducing the amount of
oxygen reaching neurological tissues; by causing bleeding (hemorrhage) into surrounding tissues; and by
compressing or displacing parts of the brain or spinal cord.

AVMs affect oxygen delivery to the brain or spinal cord by altering normal patterns of blood flow using
the arteries, veins, and capillaries. In AVMs arteries pump blood directly into veins through a
passageway called a fistula, rather than using the network of tiny vessels called capillaries which help
the blood flow to slow down. The uncontrolled blood flow into the veins is too rapid to allow oxygen and
nutrients to be distributed to surrounding tissues, causing the cells that make up these tissues become
oxygen-depleted and begin to deteriorate, sometimes dying off completely.

This abnormally rapid rate of blood flow frequently causes blood pressure inside the vessels to rise to
dangerously high levels. The arteries feeding blood into the AVM often become swollen and distorted;
the veins that drain blood away from it often become abnormally constricted (a condition called
stenosis). Also, the walls of the involved arteries and veins are often abnormally thin and weak. This can
cause aneurysms—balloon-like bulges in blood vessel walls that are susceptible to bursting—to develop.

Bleeding into the brain, called intracranial hemorrhage, can result from the combination of high internal
pressure and vessel wall weakness. Such hemorrhages are often microscopic in size (called microbleeds)
and cause limited damage and few significant symptoms. (Generally, microbleeds do not have short-
term consequences on brain function, but microbleeds over time can lead to an increased risk of
dementia and cognitive disruption. But massive hemorrhages can occur if the physical stresses caused
by extremely high blood pressure, rapid blood flow rates, and vessel wall weakness are great enough. A
burst aneurysm can release a large volume of blood into the surrounding brain and cause a catastrophic
stroke. AVMs account for approximately two percent of all hemorrhagic strokes that occur each year.
 Iloilo Doctors’ College of Medicine, Inc.
West Timawa, Molo, Iloilo City
DEPARTMENT OF SURGERY

SCC DE LA CALZADA, AIANA KATHRYNA S.

(National Institute of Neurological Disorders and Stroke, 2023).

Large AVMs can press on surrounding brain or spinal cord structures and cause damage. They can range
in size from a fraction of an inch to more than 2.5 inches in diameter, depending on the number and size
of the blood vessels making up the lesion. The largest lesions may compress several inches of the spinal
cord or distort the shape of an entire hemisphere (one half) of the brain. Massive AVMs can also
constrict the flow of cerebrospinal fluid—a clear liquid that normally nourishes and protects the brain
and spinal cord—by distorting or closing the passageways and open chambers (ventricles) inside the
brain that allow this fluid to circulate freely. The buildup of cerebrospinal fluid can cause hydrocephalus
and further increase the amount of pressure on fragile neurological structures, adding to the damage
caused by the AVM itself.

AVMs can form virtually anywhere in the brain or spinal cord—wherever arteries and veins exist. Some
are formed from blood vessels located in the dura mater or in the pia mater, the outermost and
innermost, respectively, of the three membranes surrounding the brain and spinal cord. (The third
membrane, called the arachnoid, lacks blood vessels.) (National Institute of Neurological Disorders and
Stroke, 2023).

Symptoms, which vary greatly in severity, may include.

• Seizures. Seizures can be focal (meaning they involve a small part of the brain) or generalized
(widespread), involving convulsions, a loss of control over movement, or a change in your level
of consciousness. No particular type of seizure has been identified; (+) seizures have been
manifested by the patient for the past 2 years.
• Headache. Headaches can vary greatly in frequency, duration, and intensity, sometimes
becoming as severe as migraines. No specific pattern of headache has been identified; (+)
intermittent headache has been evident as one of the first symptoms manifested by the
patient 5 years PTA. Frequency, duration and intensity is non-specific.
• Pain. You may have pain on either one side of the head or on both sides. Sometimes a headache
consistently affecting one side of the head may be closely linked to the site of an AVM. Most
often, the location of the pain is not specific to the malformation and may encompass most of
the head. Back pain in the lower extremities may be caused by a spinal AVM.
 Iloilo Doctors’ College of Medicine, Inc.
West Timawa, Molo, Iloilo City
DEPARTMENT OF SURGERY

SCC DE LA CALZADA, AIANA KATHRYNA S.

• Visual problems. An AVM can cause problems such as a loss of part of the visual field, inability to
control eye movement, or swelling of a part of the optic nerve. (+) Patient has been
complaining of blurry vision on the right visual field, eye control is also poor but inconsistent.
• Muscle weakness. You may have muscle weakness or paralysis in one part of your body. (+)
Patient is lethargic
• Problems with speech. A neurological AVM can cause difficulty speaking or understanding
language (aphasia).
• Problems with movement. You may notice a loss of coordination (ataxia) that can lead to such
problems as gait disturbances (your manner of walking); (+) patient is on soft restraints;
manifests uncoordinated movements, mostly noted during episodes of irritability or
confusion.
• Abnormal sensations. You may feel sensations such as numbness, tingling, or spontaneous pain.

AVMs also can cause a wide range of more specific neurological symptoms that vary from person to
person, depending primarily upon the location of the AVM. Such symptoms may include:

• Difficulties carrying out tasks that require planning (apraxia)

• Dizziness
• Loss of consciousness; (+) manifested by the patient 5 years PTA.
• Memory deficits
• Subtle learning or behavioral disorders during childhood or adolescence
• Confusion, hallucinations, or dementia. (+) patient is noted as GCS 14 (E4, V4, M6) confused with
orientation to time, place and person with difficulty engaging with other people.