INTERNAL MEDICINE LONG CASE 6

Student Name: Roshil Rohitesh Lal

Student ID: A00071323
Date completed: 6/09/23
Block 4 2023
PATIENT DETAILS:
Patient Initials: M.K
Age: 62
Gender: Male
Date of Admission: 1/09/2023

PRESENTING COMPLAINT(S):

62 y/o FOID male presented to ED with complains of:

 Fitting episode x 1
 Slurred speech x 1/7

HISTORY OF PRESENTING COMPLAINT(S):

Premorbid condition : According to the wife at bedside, patient has been bedridden for 4 years now,
since he had a stroke (with right sided weakness).
Patient was last well 1 day prior to presentation.
On 1/9/23 around 11pm, he was sleeping on his bed when he wife noticed that he suddenly started
having jerky movements of all his limbs, with frothing from the mouth, up rolling of eyes and urinary
incontinence. The episode lasted for about 1-2 mins and self terminated . Post ictal phase was noted.
He was confused afterwards, talking in phrases that didn't make sense hence presented to ED.

REVIEW OF SYSTEMS

+ Intermittent headache
No syncopal episode
No Cough/ SOB
No abdominal pain
No Vomiting
Normal appetite

PMHX:

 K/C/O HTN and DM2 for > 15years

 Dyslipidemia
 IHD
 Anteroseptal STEMI in 2020
 Admitted in April 2023 with Left Parietal Lacunar infarct
 Admitted in July 2023 with Re-stroke - Clinically Left ischemic CVA with right hemiparesis

Drugs: *non compliant

 Aspirin 100mg PO OD
 Clopidogrel 75mg po OD
 Simvastatin 40mg PO Nocte
 Metformin 500mg PO BD
 Metoprolol 25mg PO OD
 Amlodipine 10mg PO OD
 Phenytoin 300mg po nocte
 Omeprazole 20mg po od
Nil known allergies
FHx:
Mother and father both had HTN and DMT2 . Informant (wife) cannot recall when they passed away
or how.

SHx:

Lives in Tambuka, Lautoka with wife and grandson

Previous smoker (quit 4 years ago)
Nil alcohol or kava

On Examination
Vitals Bp- 170/96
P- 106
RR- 21
CBG- 7.9
General Drowsy and confused looking
On labetolol infusion
Nasal prongs in situ 2L O2
HEENT PEARL
No pallor
No jaundice
Moist oral mucosa
No lymphadenopathy
CHEST Clear LFS
CVS: S1S2 Regular. JVPNE
ABDO Soft and non-tender
EXT Good volume pulses, CR<2secs. Nil edema
NEURO EXAM GCS: 10/15
PEARL- 2-3mm, no neck stiffness.
Facial asymmetry on right side

Higher centers and cranial nerves difficult to assess.

Powers -
 Right side - UL 1/5 and LL 2/5
 Left side - UL 4-5/5 on and LL 3-4/5

Reflexes -
Right - Triceps 3+, Biceps 3+, Knee 2+, Ankle 1+, Babinski - downgoing
Left - Triceps 1+, Biceps 1+, Knee 2+, Ankle 1+, Babinski - downgoing

Cerebellar examination - unable to assess

Summary of Case:
Mr M.K presented to ED with a one day history of convulsions and speech disturbance. He is a known
case of DM2 and htn, noncompliant to medications, and has a past history of stroke. On examination,
he was found to have decreased powers on the right side, this was however part of his premorbid
state due to the history of stroke. Triceps and biceps reflexes were 3+ and patellar reflex was brisk on
the right while plantar was also downgoing. Reflexes on the left were normal except for brisk patellar
reflex. Higher centers, cranial nerves, and cerebellar exam was not able to be assessed due to
patient’s mental state.

PROVISIONAL DIAGNOSIS:
1. Left sided stroke with right hemiparesis
2. Seizure episode secondary to 1
3. Background DM2 and htn

Investigations:

FBC WCC: 8190 (4500- 11000)

Hb: 15.9 (13.5 -18.0 g/dL)
P/M: 48/84 (76-96/37-47)
PLTS: 166,000(150-450 x 103/microlitre)

Biochemistry U: 5.8
Cr: 102
Na: 148 K: 3.7 Cl: 110 (Nil Hemolysis)
Glu: 9.1
Chol: 6.3 TGs: 1.2 LDL: 4.6 HDL: 1.2

ECG NSR, Q-waves present

CXR Cardiomegaly
No evidence of effusion or consolidation
CT HEAD Right cerebellar bleed
Small vessel disease
Cerebral atrophy

 Blood investigations show dyslipidemia as evidenced by elevated cholesterol and LDL .

 Q waves on ECG are most commonly due to current or past MI. Other etiologies include
hypertrophic cardiomyopathy, LBBB, WPW patterns etc. (UpToDate).
 Cardiomegaly noted on CXR. Most common etiologies include dilated cardiomyopathy eg.
Secondary to HF; and left ventricular hypertrophy eg. In hypertension.
 CT scan of the head reveals haemorrhage in the right cerebellum. Features include abnormalities
on cerebellar exam i.e ataxia, vertigo, nystagmus, dysmetria, dysdiadochokinesia etc.
 Small vessel disease CT findings include lacunes, small subcortical infarcts, white matter
hyperintensities, microbleeds, and cortical atrophy. Risk factors include DM, htn, smoking,
dyslipidemia, and obesity all of which were present in the patient.

Assessment:

1. Right sided cerebellar hemorrhagic re-stroke

2. Acute seizure episode secondary to 1
3. Uncontrolled Hypertension
4. IHD
5. Cardiomegaly - likely Hypertrophic (considering HTN)
6. Dyslipidemia
7. K/C/O DM - controlled

MANAGEMENT:
Diet:
Low salt low fat diet
Swallow test positive - no need for NGT insertion

Vital Signs & Monitoring:

Neuro observation
BP profiling and control. Target BP <180/100 - If BP above target, to receive hydralazine 5mg IV stat
and repeat BP in 15mins.
Monitor for fitting episodes - Fitting Chart at bedside

Drugs - Pharmacological Management:

Drugs Mechanism of Action Contraindications Adverse Effects

Atrovastatin 80mg Inhibits HMG-CoA  Hypersensitivity  associated with
PO Nocte reductase which is the (eg, anaphylaxis, increased serum
rate-limiting enzyme in angioneurotic transaminases
cholesterol synthesis edema, erythema and
resulting in a multiforme, SJS, hepatotoxicity
compensatory rise in toxic epidermal
expression of LDL necrolysis) to  associated with
receptors on hepatocyte atorvastatin or several muscle-
membranes and any component related effects,
stimulation of LDL of the including: Myalgia
catabolism. formulation (muscle
HMG-CoA reductase  acute liver failure symptoms
inhibitors also decrease or without
levels of high-sensitivity decompensated significant
CRP, and possess diverse cirrhosis. creatine kinase
effects including [CK] elevations;
improved endothelial also known as
function, reduced statin-associated
inflammation at the site muscle
of the coronary plaque, symptoms),
inhibition of platelet Myopathy
aggregation, and (defined as
anticoagulant effects unexplained
muscle pain or
weakness
accompanied by a
CK ≥10 times the
ULN),
Rhabdomyolysis
(CK >40 times the
ULN) often with
acute renal failure
secondary to
myoglobinuria,
Immune-
mediated
necrotizing
myopathy
(IMNM) (elevated
CK plus the
presence of
antibodies against
HMG-CoA) (Ref)

Metoprolol 25mg Selective inhibitor of  Hypersensitivity  Bradycardia

PO BD beta1-adrenergic to metoprolol,  first-degree
receptors; competitively any component atrioventricularbl
blocks beta1-receptors, of the ock, second-
 with little or no effect on formulation, or degree
beta2-receptors at oral other beta- atrioventricular
doses <100 mg (in blockers block, or
adults); does not exhibit  second- or third- complete heart
any membrane stabilizing degree heart block
or intrinsic block (except in  Bronchospasm -
sympathomimetic activity patients with a selective beta-
functioning blockers like
artificial metoprolol have
pacemaker). a lower but non-
 Sinus bradycardia zero risk of
 cardiogenic shock bronchospasm
 overt heart failure compared to non-
 sick sinus cardioselective
syndrome (except beta-blockers
in patients with a  CNS effects-
functioning fatigue, sleep
artificial disturbance,
pacemaker) insomnia, vivid
 severe peripheral dreams, and
arterial memory
circulatory impairment.
disorders.
Amlodipine 10mg Inhibits calcium ions from  Hypersensitivity  Cardiovascular:
PO OD entering “slow channels”  Aortic stenosis: Peripheral edema,
or select voltage- may reduce Flushing ,
sensitive areas of coronary palpitations
vascular smooth muscle perfusion
and myocardium during resulting in  Dermatologic:
depolarization, hence ischemia. Pruritus, skin rash
causing relaxation of
coronary vascular smooth  Gastrointestinal:
muscle and subsequent Abdominal pain ,
coronary vasodilation nausea

Omeprazole 20mg suppresses gastric acid Hypersensitivity to Respiratory system

po bd secretion by inhibiting omeprazole, other PPIs disorder
parietal cells’ H+/K+ ATP or any component of Dermatologic: rash
pump hence no HCl the formulation GIT: Abdominal pain,
production. diarrhea, nausea,
vomiting
Dizziness, headache
Phenytoin 100mg IV Stabilizes neuronal  Hypersensitivity  Cardiovascular:
TDS membranes and  Sinus bradycardia, Cardiac
decreases seizure activity sinoatrial block, conduction
by increasing efflux or second- and third- disorder
decreasing influx of degree heart (depression),
sodium ions across cell block, Adams- circulatory shock
membranes in motor Stokes syndrome
cortex during nerve  Dermatologic:
impulse generation ; Bullous
prolongs refractory dermatitis,
period and suppresses exfoliative
ventricular pacemaker dermatitis,
automaticity morbilliform or
scarlatiniform
 rash

 GIT: Constipation,
nausea, vomiting

 Hematologic &
oncologic:
Macrocytosis,
megaloblastic
anemia, purpura

 Local: Injection
site reaction
(“purple glove
syndrome”;
edema,
discoloration, and
pain distal to
injection site),
local
inflammation,
local irritation,
local tissue
necrosis, localized
tenderness

 Nervous system:
Cerebral atrophy
(elevated serum
levels and/or
long-term use),
cerebral
dysfunction
(elevated serum
levels and/or
long-term use),
confusion,
dizziness,
headache,
insomnia,
nervousness,
paresthesia,
peripheral
neuropathy
(associated with
chronic
treatment),
twitching, vertigo
Metformin 500mg Decreases hepatic  Hypersensitivity  GIT - diarrhea,
po bd gluconeogenesis,  DM1 nausea,
decreases intestinal  ESKD flatulence,
absorption of glucose and  stress conditions dyspepsia,
improves insulin eg. severe vomiting, and
sensitivity thus increasing infection, trauma, abdominal pain
peripheral glucose surgery, postop  Metformin-
uptake and utilization recovery associated lactic
acidosis (MALA)
  Vitamin B12
deficiency (long-
term use)
Labetolol infusion 1 Blocks alpha1-, beta1-,  Hypersensitivity  Orthostatic
mg/mL at 30 mL/hr and beta2-adrenergic  severe hypotension
receptor sites bradycardia  Dizziness
 Second or third  fatigue
degree heart  Nausea
block
 cardiogenic shock
or
uncompensated
cardiac failure
 bronchial asthma

Sliding scale insulin stimulates cellular uptake  Hypersensitivity  Severe

of amino acids and  Hypoglycemic hypoglycemia
increases cellular episodes
permeability to  Nervous system:
potassium, magnesium, Headache,
and phosphate among hyporeflexia
other ions.
(Promotes intracellular  Respiratory:
movement of potassium Nasopharyngitis,
by activating sodium- viral respiratory
potassium ATPases) tract infection

For patients with acute haemorrhagic stroke who present with systolic SBP between 150 to 220
mmHg, the recommendation is to lower SBP to a target of 140 mmHg, ideally within the first hour of
presentation, provided the patient remains clinically stable. [UpToDate]
Agent choice :
Nitroprusside and nitroglycerin not recommended because they may increase intracranial
pressure. [UpToDate]
The Fiji Cardiovascular Therapeutic Guidelines recommend Labetalol infusion at a rate of 2
mg per minute.
Nifedipine 10mg SL is NOT recommended as the dose delivered is unpredictable and subsequent rapid
decrease in BP can lead to an ischemic stroke or MI.

Sliding scale insulin is indicated for critically ill diabetic patients as per Fiji Diabetic Guidelines.

Non-Pharmacological Management:
Supportive O2 PRN
Q2hrly turns
Physio to see

SOAP Notes:

02/09/2023 8 am
Awake, obeying commands, dysarthric
Vitals: P 75 RR 20 BP 179/113 Temp afebrile Spo2- 96% RA

Chest:
CVS: S1S2 regular
Respiratory: clear lung fields
Abdomen: soft nontender
Neuro:
GCS- improving 14/15
Powers -
RUL 1/5 and LUL 2/5
LUL 4/5 and LLL 4/5

03/09/2023 9 am
Sleepy but arousable
GCS - 10/15
Vitals - P 97 BP 160/109 SpO2 - 97% RA Temp Afebrile CBG - 8.3
CVS - S1S2 regular
Respiratory - transmitted breath sounds anteriorly
Extremities - Tone reduced on right limbs.
Moved Lt arm to localise pain

04/09/2023 9 am
Not talking
Nil fits in the ward

O/E
Awake, obeying commands
Vitals - P 101 BP 156/84 T 36.8 CBG 8.6
HEENT - Noted right sided facial asymmetry
Chest - crepitations in LLZ
Abdo - soft, non tender
Ext - Good volume pulse
Powers - RUL and LUL atleast 3/5. RLL and LLL atleast 2/5 A/

05/09/2023 8:30 am

O/E: GCS 11/15 , aphasic

Vitals: BP 165/87 P 96 RR 21 Temp afebrile SPO2- 95% RA CBG- 8.3
HEENT: mild pallor, nil jaundice
Chest: S1S22 regular, clear lung fields anteriorly
Abdomen: soft, nontender
Ext: good volume pulses

References:

 Fiji Cardiovascular Guidelines

 Fiji Diabetes Guidelines
 https://www.uptodate.com/contents/pathogenesis-and-diagnosis-of-q-waves-on-the-
electrocardiogram#
 https://www.uptodate.com/contents/spontaneous-intracerebral-hemorrhage-acute-treatment-
and-prognosis
 UpToDate entries on above-mentioned drugs