St.

Paul University PhilippinesTuguegarao City, Cagayan Valley, 3500SCHOOL

OF MEDICINE

INTERNAL MEDICINE WRITE UP CASE 6

BASSIG, MATT JOSEPH

MAGAT, JESCEL-ANNE JANEA D.
SANTOS, JULIENNE

GENERAL DATA
Patient AB is a 58-year-old male, Filipino, Roman Catholic, currently residing at Abulug, Cagayan,
and was admitted for the first time at CVMC on the 1 st of June 2020.

CHIEF COMPLAINT
Right sided body weakness

HISTORY OF PRESENT ILLNESS

History revealed that 4 hours PTA, patient woke up with numbness on his right extremities, accompanied
with confusion, sudden headache, and slurring of speech.
3 hours PTA, still with the above condition, patient was brought to a nearby hospital. Upon arrival at the
ER, he was noted to be drowsy and exhibited right sided body weakness. CT scan was done. BP was noted to be at
160/90 mmHg. Patient was then advised to transfer to CVMC immediately. However, the relative was not
compliant and instead, patient was brought home to Abulug to prepare his things before heading to CVMC, hence
subsequent admission.

REVIEW OF SYSTEMS
GENERAL (-) weight loss
INTEGUMENTARY SYSTEM (-) pruritus (-) rashes
CENTRAL NERVOUS SYSTEM (-) loss of consciousness (-) seizures
(-) tingling sensation (+) dizziness
CARDIO-RESPIRATORY SYSTEM (-) cough (-) colds (-) dyspnea (+) palpitations
(+) easy fatigability (-) orthopnea
GASTROINTESTINAL (-) dysphagia (-) constipation (-) diarrhea
(-) vomiting (-) abdominal pain
GENITOURINARY (-) hematuria
MUSCULOSKELETAL (-) myalgia (-) arthralgia
HEMATOLOGIC (-) bleeding tendencies (-) hematoma
ENDOCRINE/METABOLIC (-) weight loss (-) night sweating

PAST MEDICAL HISTORY

 No previous hospitalization

Hypertension Losartan 50mg tab OD

Hypertensive Cardiovascular Disease
Atrial Fibrillation
Carvedilol 6.25 mg tab OD
Lanoxin 0.25 mg tab OD
Atorvastatin 40 mg tab OD
Aspirin 80 mg tab OD
Spironolactone 25 mg tab OD
 Pradaxa 110 mg tab BID
 Surgery - Philippine Heart Center, 2010
o Childhood RHD - underwent Mitral Valve Valvuloplasty
 No allergies to foods and drugs

FAMILY HISTORY
MATERNAL PATERNAL
Hypertension - -
Heart disease - -
CVD/Stroke - -
Asthma - -
Diabetes mellitus - -
Cancer - -
Allergies - -

PERSONAL AND SOCIAL HISTORY

Smoking -
Alcoholic beverages -
Food preferences -

PHYSICAL EXAMINATION
Patient AB is noted to be drowsy, arousable to light stimuli, oriented to person however
disoriented to place and time. He is not in apparent cardiorespiratory distress.
VITAL SIGNS
Blood pressure 180/110 mmhg
Cardiac rate 100 bpm (irregular)
Respiratory rate 24 cpm
Temperature 38.02 °C

SKIN (-) pallor (-) jaundice (-) cyanosis

HEENT anicteric sclera, pinkish palpebral conjunctiva
(-) neck vein engorgement
CHEST AND LUNGS SCE, (-) retractions, (-) bibasal crackles, (-) wheeze
HEART dynamic precordium, PMI at 6th ICS LMCL, irregular
rate, (+) mid diastolic murmur 2/6
ABDOMEN soft and nontender
EXTREMITIES (-) pallor, (-) edema, equal pulses
NEUROLOGIC
CN VII (+) facial asymmetry
CN IX, X (+) weak gag reflex
CN XII (+) tongue deviation on the right side
MOTOR FUNCTION 3/5 right upper and lower extremities
SENSORY FUNCTION 5/5 left upper and lower extremities

SALIENT FEATURES
 58y/o, Male
 Right sided body weakness
 Numbness
  Confusion
 Headache
 Dysarthria
 Drowsiness
 Easy fatigability
 History of HPN, HCVD, AF, RHD
 Disoriented to time and place
 Hypertensive
 Irregular rhythm
 Tachypneic
 Febrile
 Dynamic precordium
 PMI at 6th ICS LMCL
 Mid diastolic murmur 2/6
 (+) Facial asymmetry
 (+) Weak gag reflex
 (+) Tongue deviation on the right side
 Decreased motor function on right upper and lower extremities 3/5

IMPRESSION
 CEREBROVASCULAR ACCIDENT probably secondary to Atrial Fibrillation
 Hypertension
 Hypertensive Cardiovascular Disease
 Left Ventricular Hypertrophy

DIFFERENTIAL DIAGNOSIS
● Intracranial Tumor
RULE IN RULE OUT
● Headache ● Chronic in presentation
● Dizziness ● Smoking
● Disoriented ● Personality or behavior changes
● Easy fatigability ● Memory problems
● Dysarthria ● Vision problem
● Hemiparesis ● Hearing problems
● Confusion ● Smell problems
● Loss of balance
● Difficulty in fine motor skills
● Seizures
● Tremors
● Unexplained nausea or vomiting

● Acute Bacterial Meningitis

RULE IN RULE OUT
● Fever ● Neck stiffness
● Headache ● Kernig’s, Brudzinki’s
● Confusion ● Nausea and vomiting
● ↓ LOC ● Photophobia
● Seizure
● Rash
 ● Metabolic Encephalopathy
RULE IN RULE OUT
● Hemiparesis ● Diabetes → Hypoglycemia
● Headache ● Liver disease → Hepatic encephalopathy
● Confusion ● Kidney failure → Uremic encephalopathy
● Disoriented ● Electrolyte imbalance
● ↓ LOC ● Heart failure
● Dysarthria ● Personality disorders
● Mood disorders
● Psychomotor hyperactivity
● Delirium
● Convulsion

● Todd’s Paralysis
RULE IN RULE OUT
● Hemiparesis ● After partial seizures/generalized tonic-clonic
● Dysarthria seizures
● History of epilepsy
● Stroke history

CASE DISCUSSION
Ischemic Stroke
Ischemic stroke is due to cerebral ischemia, caused by a reduction in blood flow that lasts longer than
several seconds . If the cessation of flow lasts for more than a few minutes, infarction or death of brain tissue results.
When blood flow is quickly restored, brain tissue can recover fully and the patient’s symptoms are only transient:
this is called a transient ischemic attack (TIA). Focal ischemia or infarction is usually caused by thrombosis of the
cerebral vessels or by an emboli from a proximal arterial source, or the heart.
In ischemic stroke, acute occlusion of an intracranial vessel causes reduction in blood flow to the brain
region it supplies. A decrease in cerebral blood flow to zero causes death of brain tissue within 4–10 min; values
<16–18 mL/100 g tissue per minute cause infarction within an hour; and values <20 mL/100 g tissue per minute
cause ischemia without infarction unless prolonged for several hours or days. If blood flow is restored to ischemic
tissue before significant infarction develops, the patient may experience only transient symptoms, particularly TIA.
Common presentation of patients with stroke includes sudden onset of any of the following:
 loss of sensory and/or motor function on one side of the body (nearly 85% of ischemic stroke patients have
hemiparesis)
 change in vision, gait, or ability to speak or understand;
 or a sudden, severe headache.
 The highlighted signs and symptoms are manifested by our patient.

Hemorrhagic Stroke
Hemorrhagic stroke is an Intracranial hemorrhage caused by bleeding directly into or around the brain; it
produces neurologic symptoms by producing a mass effect on neural structures, from the toxic effects of blood
itself, or by increasing intracranial pressure.

Epidemiology
Cerebrovascular Disease is the second leading cause of death worldwide. With 6.2 million people
dying from stroke in 2015. Stroke remains the most common disabling disease in the United States and in
many forms is preventable.
According to studies, 14% of all strokes occur during sleep, with some people visiting the
emergency room after waking up with stroke symptoms. For those who survive having a stroke while
asleep, there’s a risk of permanent disability due to delayed treatment.
 Here is a table lifted from the Philippine Statistics Authority (PSA) and the Department of Health
(DOH) showing the top three killers of Filipinos, 2nd of which is Diseases of vascular system and under it is
cerebrovascular disease or stroke.

Etiology
The TOAST (Trial of Org 10172 in Acute Stroke Treatment) Classification system is being used to
better classify ischemic strokes that patients had suffered on the basis of etiology, as this had an impact
on the patient’s prognosis and risk of stroke recurrence. It denotes five subtypes of ischemic stroke: First
one, the 1) Stroke of undetermined etiology 2) cardioembolism, 3) small-vessel occlusion, 4) large-artery
atherosclerosis, and 5) stroke of other determined etiology.
Given the history of our patient with co-existing Atrial Fibrillation, it predisposes him to
cardioembolic cause of stroke. Furthermore, it has the highest incidence of all causes ischemic stroke,
accounting to 29%.

PATHOPHYSIOLOGY
DIAGNOSTIC TEST
I. Stroke Assessment II. Atrial Fibrillation III. Left Ventricular Hypertrophy
Neurological  E12-Lead Electrocardiogram  Chest X ray
 NIHSS  Holter monitoring for 24-48
Laboratory and Neuroimaging hours
 CBG  Echocardiogram (TTE/TEE)
 CBC and PC
 PT/PTT
 Serum Electrolytes
 ABG
 Cardiac biomarkers
Troponins
BNP, NT-proBNP
 Lipid Profile (TC, LDL, HDL)
 BUN, Crea
 AST/ALT
 ESR
 Urinalysis
 Plain Cranial CT Scan or MRI
 Cerebral Angiography
 Carotid Ultrasound
MANAGEMENT
Management for Ischemic Stroke
A. Oxygen Supplementation: 2-3 L/min
B. BP Management:
 Allow permissive hypertension, treat only if BP exceeds 220/120 mmHg
 Nicardipine IV 5 mg/hr continuous, titrate by 2.5 mg/hr q5-15 min. Max 15 mg/hr
C. Thrombolytic Therapy: IV Recombinant Tissue Plasminogen Activator (rt-PA): Alteplase
 Time window: 3-4.5 hours
 Dose: 0.9 mg/kg (max dose of 90 mg) over 60 minutes with initial 10% dose given as bolus over 1 minute.
D. Endovascular Therapy (Mechanical thrombectomy)
 Indications: prestroke MRS score of 0-1, causative occlusion of the ICA or M1 segment, >18 years old, NIHSS
score of >6, alberta score program early CT score ≥6, receive treatment (groin puncture) within 6 hours of
symptom onset, large-vessel occlusion in the anterior circulation
 Recommended for selected patients with acute ischemic stroke within 6-16 hours (DEFUSE Trial 3) up to 24
hours (DAWN Trial)
 Beneficial if added to IV rt-PA among patients with intracranial ICA, M1, or M2 occlusion
E. Antithrombotic therapy
 Cardioembolic Stroke: CHA2DS2-VASc score (4 pts), HAS-BLED score (2 pts)
 Warfarin
 DOAC: Dabigatran 150 mg BID
F. Surgical Treatment
 Decompressive hemicraniectomy with dural expansion: unilateral MCA infarction who deteriorate
neurologically within 48 hrs
G. Neuroprotection (5H Principle)
 Avoid Hypotension: Target MAP: 110-130 mmHg
 Avoid Hypoxemia: Target O2 sat: >94%
 Avoid Hypo/Hyperglycemia: Target CBG: 140-180 mg/dL. Use 0.9 NaCl
 Avoid Hyperthermia: Target: Normothermia. Antipyretics and cooling blankets

Management of Atrial Fibrillation

A. Rate Control:
 Beta blockers (Propranolol 10-30 mg q6-8hr)
 Calcium Channel Blockers (Verapamil 240 to 320 mg/day orally in 3 or 4 divided doses)
 Digoxin
B. Rhythm Control:
 Amiodarone 400-600 mg/day in divided doses for 2-4 wk; Maint, 100-200 mg QD
C. Anticoagulation Therapy:
 Warfarin
 Dabigatran 150 mg BID

FINAL DIAGNOSIS
 Acute Ischemic Stroke (Moderately Severe NIHSS 11), Left MCA, secondary to Valvular Atrial Fibrillation
 Stage II Hypertension
 Hypertensive Cardiovascular Disease
 Left Ventricular Hypertrophy