Arciaga, Frances Geline R.

March 23, 2023

4MD Neurology

Date of interview: March 21, 2023

Time of interview: 5:00 PM
Informant and Reliability: Patient Himself (95%) and his wife (80%)

General Data:
V.P., a 79-year old male, right-handed, married, a Roman Catholic, born on April 19, 1943 in Manila
and currently residing at Tugatog, Malabon City, was admitted for the first time at MCU-FDTMF Hospital
last March 18, 2023.

Chief Complaint:
Right-sided body weakness

History of Present Illness:

On March 18, 2023 at 10:45 am prior to admission, the patient was in his usual state of health while
watching television when he suddenly complained of non-rotatory dizziness. His wife then noted that he
also had difficulty in talking so she asked him to raise his hand, which he was unable to do. No other
associated symptoms such as headache, dizziness, loss of consciousness, nausea and vomiting were noted.
No medications were taken nor consultation was done at the time. Persistence of symptoms thus prompted
the patient to seek consult in the Emergency Room of MCU Hospital and was subsequently admitted.

Past Medical History:

No allergy to food and medication. Diagnosed with Hypertension for more than five years, has
unrecalled maintenance medications but is noncompliant. Patient claims his highest blood pressure was
140/90 mmHg. Diagnosed with Hyperuricemia for more than ten years now but also with unrecalled
medications. He underwent Lithotripsy ten years ago at Manila Doctors Hospital. With complete
vaccination. No history of blood transfusions. He denies having illnesses like hepatitis, tuberculosis, renal,
psychological, and hematologic diseases.

Family History:
Patient has a family history of lung cancer from the paternal side. He also has a family history of
hypertension, hyperuricemia and kidney failure from the maternal side. No family history of tuberculosis,
cancer, stroke, myocardial infarction, epileptic, renal, psychological, and hematologic diseases.

Personal Social History:

Patient is a retired school administrator. He denies to smoking but occasionally consumes 3 beer
and wine which started when he was 30 years old. His diet consists of eating fried food and vegetables.

Review of Systems:
 General:
o No fever episode, weakness, fatigue
o No recent weight gains or weight loss
 Skin
o No skin infection, rashes, lesions or lumps, sores and itching noted
  Head and Neck:
o No history of head injury, dizziness, headache
o No pain, redness, excessive tearing, double vision, flashing lights
o No hearing problem, earache, itching and discharge, tinnitus
o No decreased visual acuity reported, wears prescription glasses
o No anosmia and nasal polyps
o No gum bleeding, neck stiffness, rigidity and pain noted.
 Cardiovascular
o No orthopnea, paroxysmal nocturnal dyspnea, palpitations, murmurs, tachycardia, chest
pain
 Respiratory
o No cough, hemoptysis, wheezing, stridor, difficulty of breathing
 Gastrointestinal
o No nausea and loss of appetite
o No vomiting
o No diarrhea, dysphagia, jaundice, constipation and indigestion
 Genitourinary
o No tea-colored urine, and nocturia
o No dysuria, incontinence, urinary urgency
o No pain and swelling in the genitalia
 Peripheral vascular
o No muscle cramps, varicosities
 Musculoskeletal
o No joint pains, muscle weakness
o No back pain noted
 Neurologic
o No loss of sensation and numbness reported
 Hematologic
o No easy bruising, pallor absent
 Endocrine
o No heat and cold intolerance, excessive sweating, enlarged thyroid
o No polydipsia, polyphagia, polyuria
 Psychiatric
o No anxiety disorder, bipolar disorder, hallucinations

PHYSICAL EXAMINATION
General Survey:
Upon admission, patient was seen wheelchair-borne but alert, conscious and conversant. He was
oriented to time, place, and person, and looks appropriate for his age. Hair was well-kempt and no
malodorous scent was noted. No cardiac or respiratory distress was noted. No involuntary movement and
gross deformity noted. The patient had a normal built and short hair, was wearing a shirt, a pair of shorts
and slippers.
Vital Signs:

BP = 180/100 mmHg PR = 65 beats per minute RR = 21 cpm

Temp. = 36.3 OC O2= 98% at RA Pain scale = 0/10
Height = 167.64 Weight = 70kg BMI= 24.9 kg/m2 (normal)

Skin: Skin is brown in color, moist, warm to touch and smooth. It is elastic with good skin turgor. Hairs are
black in color with normal distribution. Nails are clean with pinkish nailbeds and capillary refill time of less
than 2 seconds. No clubbing noted.

Head: Skull is normocephalic. Hair is well distributed and black in color.

Eyes: Eyebrows are symmetrical with equally distributed fine hairs. No matting, no erythema, no lesions,
anicteric sclerae, pink palpebral conjunctivae, with pupils 2-3mm equally reactive to light, no nystagmus.

Ears: No discharge, lumps or tenderness. He can hear and answer clearly when prompted with questions.
Tympanic membranes were not examined.

Nose: Symmetrical. No nasal flaring, sinus tenderness, nasoaural discharges. With shallow nasolabial fold,
right.

Thorax and Lungs: Thorax is elliptical in shape, symmetrical in expansion with no deformity and skin lesion.
Breathing is quiet and regular with no use of accessory muscles of respiration. Equal chest expansion upon
palpation as well as the tactile fremitus on both lung fields anteriorly and posteriorly. No palpable area of
tenderness and no mass was noted. On percussion, lung fields are predominantly resonant except on the
cardiac area anteriorly and scapular areas posteriorly. Breath sounds are predominantly vesicular in both
lung fields anteriorly and posteriorly except on the area of trachea and manubrium, which are tracheal and
bronchial in nature. Vocal fremitus is equal in both lung fields anteriorly and posteriorly with no
adventitious sounds noted.

Cardiovascular: No precordial bulging, mass or visible skin lesions noted. No heaves and thrills noted. PMI
is at 5th ICS left midclavicular line. JVP not measured, carotid pulse with brisk upstroke. Regular rate and
rhythm. No murmur appreciated. The intensity of S1 is greater than S2 at the apex and intensity of S2
greater than S1 at the base.

Abdomen: The stomach is symmetrical and flat, with no dilated vein, no mass or lesions, pulsation,
peristalsis observed. There are no bowel sounds, No bruit on the renal and iliac arteries as well as on the
abdominal aorta.

Genitalia/Rectal: Examination not made.

Neurologic:
Mental Status Examination: The patient was seen awake, relaxed, cooperative, non-combative,
looks appropriate for age and well-kempt. The patient converses normally and is tangential. Mood and
affect are appropriate, has no delusions, hallucinations, and derealization or depersonalization. He is
bright and not suffering from a mental disability. He has a normal attention span, and oriented to the
three spheres with intact recent and remote memory. He was able to do calculations and has good insight
and judgment. GCS 13 (E4V3M6)
 Cranial Nerves:
I: can smell coffee on each nostril
II: OD: 20/40 (5-1) OS: 20/40; normal visual field test, pupils equally constrict and dilates,
no flame, dot, papilledema, hard exudates, and retinal edema on fundoscopy.
II & III: pupils constrict on direct and consensual response.
III, IV & VI: no ptosis, pupils constrict, no deficit on extraocular movement
V: Can feel light touch and pain sensation over all three divisions of the face.
VII: Can crease up the forehead, can keep eyes closed against resistance, can smile and
reveal the teeth, and can puff out the cheeks.
VIII: Can hear snapping of fingers, Rinne’s test: Air conduction > Bone conduction;
Weber’s test: Lateralizes to the right ear
IX & X: No swallowing difficulties and has intact gag reflex.
XI: Can rotate head against resistance and can flex the head against resistance, can
perform shoulder shrugging.
XII: Can protrude tongue on midline, and lateral movement, no atrophy and
fasciculations.
Motor:
RUE - 3/5 RLE - 3/5
LUE - 5/5 LLE - 5/5
- With pronator drift towards the right
- With hemiparesis, right
Cerebellum: No presence of dysmetria and dysdiadochokinesia.
Somatosensory: With intact joint position sense.
Meningeal Irritation: No nuchal rigidity, negative for Brudzinski and Kernig sign.
Deep Tendon Reflexes: 2+ on biceps, brachioradialis, achilles, triceps, patellar and
plantar reflexes
Sensory: 100% on all extremities

Differential Diagnosis Rule In Rule Out

Subdural hemorrhage (+) Age: 79 years old
(+) non-rotatory dizziness
(+) right-sided body weakness
(+) 3/5 RUE and RLE
(+) shallow nasolabial fold
(+) GCS 13 (E4V3M6)
(+) PMH: Hypertension
(+) noncompliance to
medications
(+) FMH: Hypertension
(+) PSHx: Alcoholic drinker
(+) inactive lifestyle
(-) Personality changes
(-) Headache
(-) Dizziness
(-) Nausea / Vomiting
(-) Head trauma or history of head trauma
(-) Vision problems
(-) Balance issues
HPN (-) Changes in mental function
(-) CT scan finding of cresentic bleed

Brain tumor (+) Age: 79 years old (-) Personality changes

(+) non-rotatory dizziness (-) Headache
(+) right-sided body weakness (-) Dizziness
(+) 3/5 RUE and RLE (-) Nausea / Vomiting
(+) shallow nasolabial fold (-) Seizure
(+) GCS 13 (E4V3M6) (-) Vision problems
(+) PMH: Hypertension (-) Hearing problems
(-) Balance issues
 (+) noncompliance to HPN (-) Changes in mental function
medications (-) Head trauma or history of head trauma
(+) FMH: Hypertension (-) FMH of tumor
(+) PSHx: Alcoholic drinker (-) CT scan finding of a mass
(+) inactive lifestyle
CVA – Infarct (+) Age: 79 years old
(+) non-rotatory dizziness
(+) right-sided body weakness
(+) 3/5 RUE and RLE
(+) shallow nasolabial fold
(+) GCS 13 (E4V3M6) (+) PMH:
Hypertension
(+) noncompliance to HPN
medications
(+) FMH: Hypertension
(+) PSHx: Alcoholic drinker
(+) inactive lifestyle
(+) onset and duration of symptoms

CLINICAL IMPRESSION: CVA-Infarct, Left Middle Cerebral Artery Territory; NIHSS – 8; HCVD

MANAGEMENT:
- IVF: PNSS 1L x 60cc/hour
- Diet: Low salt, low-fat, low purine diet with strict aspiration precaution
- Diagnostics:
o CBC PC o PT PTT
o Na, K o Plain cranial CT scan
o HGT o 2D Echocardiography with doppler
o BUN o Plain cranial CT scan
o Crea o FBS
o 12 L ECG o Lipid profile
o Chest Xray
- Therapeutics:
o Aspirin 80mg/tablet, 1 tablet once a day
o Atorvastatin 40mg/tablet, 1 tablet once a day
o Soludexide 600 LSU/IV, once a day
o Cilostazol 100mg/tablet, 1 tablet once a day
o Citicoline 1g/IV, every 12 hours
o Selenta capsule, two capsules twice a day every 12 hours
o Omeprazole 40mg/IV, once a day before breakfast
o Losartan 50mg/tablet, 1 tablet once a day
- Watch out for recurrence of symptoms