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CASE DISCUSSION OF A PATIENT

WITH
RIGHT-SIDED BODY WEAKNESS
Rey Kevin Q. Garcia, Post-Graduate Intern, AUFMC

IDENTIFYING DATA

35 y/o, male

Married, Filipino, Roman Catholic

Currently residing in #35 General Ricarte St., Kalayaan


Subdivision, Angeles City

Admitted in AUFMC for the first time last May 12, 2015

Medical student

Informant: Patient; Reliability: 75%

Chief Complaint: Right-sided body weakness

35 y/o male
S>
1 week PTA:

(+) Weakness of the right leg (more prominent) and right


arm

(+) Numbness over the right arm, right leg and lower right
side of the face

(-) Headache, (-) dizziness; (-) visual changes, (-)


dysarthria, (-) dysphagia; (-) Loss of consciousness, (-)
change in sensorium, (-) seizure activity

Pt was brought to the ER of RLMMC No management


done (?) Sent home

35 y/o male
S>

4 days PTA:

(+) Weakness of the right leg, right arm (decreased in


severity)

(+) Numbness over the right arm, right leg and lower right
side of the face

(+) Instance of unconsciously pushing the door with his left


hand with the intent of pushing the door with his right
hand

(+) Reports difficulty in playing the drums

Motor & sensory deficit progressively decreased in


severity over the week

35 y/o male
S> (Cont.)

Day of Admission

(+) Weakness of the right leg, right arm (decreased in severity)

(+) Decrease in sensation over the right arm, right leg and lower right side
of the face

Sought consult and was hence admitted

PAST MEDICAL HISTORY

(+) Stroke/TIA (?) 2014; lateralizing weakness (left) lasting for <24h
CT-scan no abnormalities seen; no residual symptoms

(+) Hypertension since 2010; maintained on Amlodipine 5 mg/tab 1 tab


OD and Losartan 50 mg/tab 1 tab OD; highest BP = 190/100, usual BP140/80

(+) Diabetes Mellitus since 2010; maintained on Metformin 500 mg/tab


OD; claims to have good compliance
(-) Heart disease , (-) Lung disease, (-) Kidney disease, (-) Asthma, (-)
Allergies

35 y/o male
S> (Cont.)

FAMILY HISTORY

(-) Stroke

(-) Other neurologic (brain) disease

(-) Heart disease

(+) Hypertension maternal uncle (onset at age 50)

(+) Diabetes mother (type 2)

PERSONAL/SOCIAL HISTORY

(+) Smoker 3 pack years

(-) Chronic alcohol drinker

ENVIRONMENTAL & DIET HISTORY

Proclivity for food high in salt, fat and preservatives (e.g. sisig,
tocino)

35 y/o male
O>

General: Conscious, coherent, not in cardiorespiratory distress

Vital Signs: BP- 160 / 110 mmHg; HR- 78 bpm; RR- 20 cpm; T- 36 C

Skin: No jaundice, no cyanosis, no pallor

HEENT: Anicteric sclerae, pink palpebral conjunctivae; fundoscopy: (+)


ROR; no cervical lymphadenopathy, no jugular vein distention

Chest: Symmetric chest expansion, no retractions, clear breath sounds

Heart: Adynamic precordium, no heaves, no thrills, PMI on 5 th ICS MCL,


normal rate, regular rhythm, no murmurs

Abdomen: Soft, flabby, normactive bowel sounds, non-tender on all


quadrants

Extremities: Full and equal pulses, full range of motion, brisk capillary
refill

35 y/o male
O> (Cont.)
Neurologic Exam:

MSE: Conscious, coherent;


Oriented to time, place and
person; Short term, recent, long
term and remote memory intact,
Good concentration, can do simple
calculation, can do a 3 step
command
Cerebellar:
o

Can perform nose-to-fingertip test

Can perform heel-to-shin test

Unsatisfactory rapid
supination/pronation test

Meninges: No nuchal rigidity, no


brudzinski, no kernigs

Reflexes: (-) babinski on both feet

Right

4/5 7080%

100%

100%

7080%

100%

+
++

5/5 100%
+
+ +
+

+
4/5 7080%

Left

+
+

+
+

5/5 100
%

35 y/o male
Neurologic Exam:

Cranial Nerves
Cranial Nerve

Response

Not assessed

II

(+) ROR, Pupils 3-4 mm, equally reactive to


light

III, IV, VI

Intact EOMs, No preferential deviation of


gaze

(+) Corneal reflex, can clench jaw;


decreased sensation on lower part of the
right face (70-80%)

VII

Intact mimetic muscles; (+) corneal reflex

VIII

Can hear on both ears

IX, X

(+) Gag reflex

XI

Can turn head on both sides, can shrug


shoulders

Approach to Neurologic
Disease
Is there a lesion?

Yes. (Suggested by the right sided body weakness,


numbness)

Where is the lesion?

Levelize Supratentorial
Localize Cerebral hemisphere, ACA territory
Lateralize Left

What is the lesion?

Vascular etiology Stroke (Ischemic vs


Hemorrhagic)

Ischemic vs Hemorrhagic
Stroke
Ischemic Stroke (Infarct)

Hemorrhagic Stroke (Bleed)

Consciousness relatively
preserved (variable)

More depressed level of


consciousness

Lower initial blood pressure

Higher initial blood pressure

Deficit maximal at onset or


remits

Worsening of symptoms after


onset

Moderate / no headache

Severe headache

Herniation rare/late

Early signs of herniation

* Harrisons Principles of IM, 18 th ed


* Brown et al, CVA/Stroke, 2007

35 y/o male
A>
Initial Impression:
Cerebrovascular Accident, probably infarct, left

cerebral hemisphere
Diabetes Mellitus Type II, Non-insulin requiring
Hypertension Stage II, uncontrolled

35 y/o male
P>

Diagnostics:

CBC

Serum Crea, Na, K

RBS

Chest X-ray PA View

ECG

Plain Cranial CT-scan

Lipid profile, serum FBS in AM

Activity: CBR without BRPs

Diet: LSLF

IVF: PNSS 1L x 8h

CBC (5/12/2015)
Examination

Result

Reference Range

Hematocrit

0.43

0.41-0.50

Hemoglobin

147

140-175 g/L

Leukocyte count

9.57

4.50-11.00 x
10^9/L

Neutrophils

0.61

0.18-0.70

Lymphocytes

0.32

0.10-0.48

Monocytes

0.06

0.00-0.04

Eosinophils

0.01

0.00-0.03

Platelet

398

150-400 x 10^9/L

Clinical Chemistry (5/12/2015)


Examination

Result

Reference Range

Creatinine

1.34

0.79-1.56 mg/dL

Potassium

4.65

3.5-5.50 mmol/L

137.6

135-150 mmol/L

270.36

mg/dL

Sodium
Glucose (RBS)

CT-Scan (5/12/15)

Working Diagnosis
CVA infarct, left corpus callosum; ACA region
r/o Demyelinating Disease (MS)
Diabetes Mellitus Type II, Non-insulin requiring
Hypertension Stage II, uncontrolled

P> (Cont.)
Therapeutics

Problem: CVA infarct

Citicholine (Cholinerv) 1g IV BID

Clopidogrel 80 mg/tab 1 tab OD

Rosuvastatin 10 mg/tab OD

Omeprazole (Omevex) 40 mg OD

Maintain SBP to 140-160 mmHg

Problem: Hypertension

Losartan 50 mg/tab 1 tab OD

Amlodipine 5 mg tab OD

Problem: Diabetes II

Metformin 500mg/tab 1 tab OD

HOSPITAL DAY 3