Case Discussion

WARDWORK GROUP 4B
MAGLALANG, HAROLD
MALAZO, JOHN PHILIP
MALIMBAN, OLIVER
MALOLES, SHANE
TIBAYAN, LOVELY BETH
 General Data

 E.C. 52 years old, Male, Filipino, Roman Catholic,

born on August 28, 1964 at Iligan, Mindanao,
currently residing at Imus City, Cavite, right-handed,
was admitted for the 1st time at DLSUMC on March
27, 2017.
 Chief Complaint

 Right sided hemiplegia

 Hiatory of Present Illness

 2 days PTA, numbness and weakness on Right upper

and lower extremities. No associated symptoms
noted. No medications taken.
 1 day PTA, numbness and weakness persisted with
accompanying loss of balance. No medications and
consultations done.
 History of Present Illness

 On the day of admission, patient’s condition

worsened. Unable to raise right arm and leg.
Patient’s wife decided to seek help. Patient vomited
twice during travel.
 Past Medical History

 23 years PTA, patient accidentally was electrocuted

with 24K volts which made him sustain burn injuries
on his left knee. Treated at the hospital.
 Unrecalled years PTA, patient accidentally shot
himself in his arm. Self-treated.
 3 years PTC – diagnosed with HPN.
 No other diseases, allergies, and medications noted.
 Family History

 Father – known Hypertensive

 Nutritional History

 Fond of eating vegetables and meat.

 Personal and Social History

 Patient worked as an mechanic

 Known smoker, 25 pack years
 Drinks alcoholic beverages, 1 glass a night, 2 – 5
times a week
 He jogs every morning and plays basketball.
 Patient lives with his wife, daughter, and mother-in-
law
 Water for drinking is mineral water
 Review of Systems

A. General: (-) easy fatigability, (+) weakness 60%, (-) weight gain,
(-)loss of appetite, (+)weight loss 25% (-) low grade
fever
B. Integument: (-) clubbing of nails, (-) itchiness, (-)erythema, (-)pallor,
(-)cyanosis
C. Eyes: (-)pain, (-)redness, (-)discharge, (-) pale conjunctiva,
(+) corrective lenses, (-) astigmatism
D. Ears: (-)tinnitus, (-)vertigo, (-)hearing loss, (-)discharge
E. Nose and Sinuses: (-)coryza, (-)epistaxis, (-)obstruction, (-) watery
discharge
F. Mouth and throat: (-)caries, (-) enlarged tonsils, (-)ulcers, (-)sore throat
(-)toothache, (-)dysphagia
G. Head and neck: (-)dizziness, (-)headache, (-)stiffness, (-)distended veins,
(-) enlarged neck mass
 Review of Systems
H. Respiratory: (-)cough, (-)subcostal retractions, (-) use of accessory
muscles, (-) pleuritic chest pain, (-) dyspnea, (-)
hemoptysis, (-) whitish phlegm,
I. Cardiovacular: (+)palpitation, (-) tachycardia
J. GIT: (-)diarrhea, (-)constipation, (-)melena, (-)hematemesis,
(-)hematochezia, (-)vomiting, (-) regurgitation
K. GUT (-)oliguria, (-)dysuria, (-)nocturia, (-)flank pains,
(-) hematuria, (-) increased frequency
L. Hematologic: (-)easy bruising, (-)easy bleeding, (-)pallor
M. Endocrine: (-) cold intolerance(-)polyuria, (-)polyphagia, (-
)polydypsia,
(-) heat intolerance, (-) excessive sweating
N. Musculoskeletal: (-) joint pains, (-) edema, (-)fracture, (-) numbness of
extremities
O. Nervous System: (-)seizure, (-)tremors
P. (-)Fecal incontinence, (-)Urinary incontinence
Physical Examination
 General Survey

 The patient is well developed, well nourished, awake,

conscious and coherent, oriented to time, place, and
person, bed-ridden, is not in cardio-respiratory
distress, not orthopneic and looks chronological to
his age of 53. He wears a nasal cannula. IV line on
the left arm.
 Vital Signs

 BP: 200/110 mmHg

 PR: 98 bpm
 HR: 97 bpm
 RR: 24 cpm
 Temp.: 36.7 C
 Examination of the Skin

A. General Characteristics
I. Inspection - Normal skin color. No signs of edema.
II. Palpation - Normal skin temperature (not febrile nor cool
to touch). Prompt return of skin. Moist, soft, and resilient skin.

B. Skin Lesions: Patchy skin discolorations noted at the left lower limb
(below the knee) of the patient. There is also presence of scarring on
the area medial to the left knee of the patient.

C. Skin appendages
I. Hair: Black, dense, well distributed, (-) hair loss
II. Nail unit: (-) clubbing, good capillary refill <2 sec, (-) lesions

D. Mucosal changes: (-) oral, nasal, and conjunctival lesions, (-)

mucosal redness
 Examination of the Head and Neck, Eyes, Ears,
Nose and Throat

A. Head and neck

Head: symmetrical, (-) masses
Face: Symmetrical facial landmarks
(-) cervical lymph node (-) tenderness
(-) Parotid/ submandibular enlargement
Trachea is midline and moves with deglutition
Carotid pulsations are equal
B. Eyes
Both eyes are reactive to light
(direct/consensual)
Pupil size: 4mm
Eyes in midline and symmetrical;
Conjunctiva pale in color
Sclera: white with non-prominent blood vessels
EOM intact
(+) ROR
Tonometry: Soft
C. Ears
Pinna and periauricular area is mobile with (-)
lesion, (-) mass, (-) deformity, (-) tenderness
External ear canal opening patent
Otoscopy was not performed
D. Nose
External nose: symmetrical, (-) gross deformity,
(-) mass, (-) tenderness
Midline nasal septum
E. Oral cavity and pharynx
Lips: symmetrical, pinkish, (-) mass, (-)
ulcerations, (-)dryness
Tongue is in midline
Symmetric rise of uvula and palate
Oral mucosa: no ulcers, no cyanosis
 EXAMINATION OF THE CHEST AND
LUNGS

A. Inspection
Symmetrical chest and symmetrical expansion, No
intercostal retractions and use of accessory muscles. No
deformities noted.
B. Palpation
Equal tactile fremitus on both lungs.
C. Percussion
Resonant on all lung fields.
D. Auscultation
Normal breath sounds. (-) inspiratory and
expiratory adventitial sounds
 EXAMINATION OF THE
CARDIOVASCULAR SYSTEM

A. Inspection
No precordial bulging
B. Palpation
Heaves and thrills absent
C. Percussion
Not done.
D. Auscultation
No abnormal heart sounds heard, no murmurs,
no bruits, normal rhythm.
 EXAMINATION OF THE ABDOMEN

A. Inspection
Flat, symmetrical, without any visible scars, lesions, and
discoloration noted. Umbilicus is inverted.
B. Ausculation
Normal bowel sounds: 6 bowel sounds/min
C. Palpation
No tenderness and masses noted. No palpable organs.
D. Percussion
Liver palpation: 10 cm along the right midclavicular line
Abdominal quadrants are all tympanitic
Traube’s space is intact.
E. Special Maneuvers
Rovsing’s sign is absent
Neurologic Examination
 Mental Status Examination

 The patient’s general behavior was normal, dressed

appropriately according to age and occasion, slurred
speech but moderate stream of talk, his mood is
appropriate to his affect, not agitated, there are no
presence of hallucination, delusion or illusion. The
patient is conscious, attention span is normal,
oriented to three spheres (time, place and person).
The patient’s remote, recent and immediate memory
is good. Can read but he cannot write do to weakness
of right extremity. Fund of information is good, he
was able to calculate and insight and judgment is
good.
 Cranial Nerve Examination
CN FINDINGS

I Able to smell, patient was able to recognize the smell of coffee on both
nostrils
II (+) Direct and Consensual light reflex

III, IV, VI Intact ROM of both eyes in all visual fields

V Good masseter and temporalis tone, V1, V2 and V3 has equal facial
sensation
VII (+) facial symmetry, can taste on the anterior ⅔ of tongue
Shallow nasolabial fold, Asymmetric facial expression
VIII Normal hearing

IX, X, Speech is normal, (+) coughing, (+) swallowing, (+) gag reflex

XI Good trapezius tone and SCM tone on the left side. Right side was
weak.
 Motor Examination

2/5 5/5

2/5 5/5
Sensory Examination

60% 100
%

60% 100
%
 Cerebellar Examination

Nystagmus –negative
Tandem Walk - patient is not ambulatory
Finger-to-nose test (Dysmetria) -
negative
Dysdiadokinesia -not done
 Meningeal Exam

(-) Passive Neck Flexion

(-) Kernig’s
(-) Brudzinski
 Higher Cerebellar Functions

 Aphasia
(-) Expressive (of spoken language)
Expressive (of written language) patient cannot write on his left
hand
(-) Word repetition
 Apraxia
(-) Ideomotor Apraxia -patient is able to demonstrate how to light
a match (though only using his left hand)
(-) Dressing Apraxia - not done
Constructional Apraxia - patient cannot draw or write on the right
hand
Gait Apraxia - patient cannot walk
 Agnosia
(-) Astereognosia
(-) Agraphognosia
(-) Finger agnosia
Clinical Assessment
 Primary Diagnosis

 Impression: Ischemic Stroke secondary to

uncontrolled hypertension and diabetes
mellitus type 2
 Bases
History PE
52 years old Right sided hemiplegia
Gradual onset Slurred speech
Right side Hemiplegia Cannot write due to right upper
Palpitation extremity weakness
Known Hypertensive since 2014 BP 200/110 mmHg
Smoking 25.5 pack years Shallow nasolabial fold; asymmetric
Numbness face
Weakness 2/5 muscle strength right upper and
Vomiting lower extremity
Uncontrolled Hypertension
Uncontrolled Diabetes
Use of corrective lenses (possibly
diabetic retinopathy)
 Differential Diagnosis

 Hemorrhagic Stroke
Rule in:
Right side hemiplegia, Projectile vomiting,
Diagnosed hypertensive and diabetic since 2014 that is
unmonitored, Family history of hypertension (father),
Smoking, PE: right side weakness, Asymmetric facial
expression, Shallow nasolabial fold
 Differential Diagnosis

 Hemorrhagic Stroke
Rule out:
Cannot be totally ruled out without CT SCAN
Gradual progression of symptoms
 Differential Diagnosis

 Hypertensive Emergency
Rule in: Right side Hemiplegia, Palpitation, Projectile
vomiting, Diagnosed hypertensive and diabetic since
2014, unmonitored, Family history of hypertension
Rule out: Cannot be fully ruled out. Extensive
Laboratory examinations must be done to know if
there is Neurologic organ damage.
 Transient Ischemic Attack
Rule in: Right side Hemiplegia, Weakness, BP
200/110, Family history of hypertension
Rule out: Right side Hemiplegia did not resolve after
24 hours
 Brain Neoplasm or Tumor
Rule in: Right side hemiplegia, Weight loss, PE: right
side weakness, Asymmetric facial expression, Shallow
nasolabial fold
 Rule out: Symptoms of patient is sudden in onset, (-)
headache, Imaging must be done in order to fully
rule-out.
 Meningitis
Rule in: Focal neurologic signs, vomiting, Weight loss
Rule out: Classic Triad is absent: (-) fever, (-)
headache, and (-) Neck stiffness
(-) kernig’s sign
(-) brudzinski sign
 CASE DISCUSSION

 This is a case of EC, a 52 year old male and a known

hypertensive, who presented with Right side
hemiplegia and slurring of speech. It was his first
admission in DLSUMC on March 27, 2017.
 Two days prior to admission, he felt numbness
(paresthesia) and weakness (hemiparesis) on
his right upper and lower extremities.
 This persisted until the day of his admission, in
which his signs and symptoms worsened--that is,
the patient lost his balance altogether, and this
was accompanied with slurring of speech.
 During their travel to the hospital, the patient
vomited twice, which was projectile in character with
bolus content around 2 glass full in volume. The
patient arrived in DLSUMC on March 27, 2017 at
around 5pm.
 Cerebrovascular accident is an abrupt onset of
neurologic deficit and could be due to ischemia or
hemorrhage. It can be diagnosed clinically and with
the use of different imaging studies such as MRI, CT-
scan, and angiography.
 Ischemic stroke, which is more common, is due to
the occlusion or narrowing of the arteries or total
occlusion of an artery causing a decreased blood
supply in certain parts of the brain. On the other
hand, Hemorrhagic stroke is due to a rupture of
blood vessels that could be caused by hypertension,
trauma or rupture of an aneurysm or arteriovenous
malformation.
 Our primary impression is Ischemic Stroke
Secondary to Uncontrolled Hypertension and
Diabetes Mellitus Type 2. Patient is a known
diabetic and hypertensive since 2014 and chronic
smoker, predisposing him to atherosclerosis.
 Due to uncontrolled diabetes and hypertension with
the predisposing risk factors, thrombus formation on
atherosclerotic plaque could possibly embolize into a
intracranial artery producing artery to artery embolic
stroke causing small vessel brain ischemia.
 Possibly the patient had a ischemia in the brain due
to uncontrolled hypertension and uncontrolled
diabetes. Using the 3L (Levelization, Localization
and Lateralization), we can localize the patient’s
lesion.
 For the levelization, it could be central and
supratentorial, lateralization is left sided and we can
localize the lesion due to the presenting symptoms of
the patient such as weakness of contralateral arm
and leg with dysarthria and no sensory deficit.
 Possibly the occlusion of lenticulostriate vessel
produces small-vessel stroke within the internal
capsule. This produces pure motor stroke or sensory-
motor stroke contralateral to the lesion. Ischemia in
the internal capsule causes primarily facial weakness
followed by arm and then leg weakness as the
ischemia moves posterior within the capsule.
Management
 Diagnostics

 CBC
 Coagulation studies
 Non Contrast CT
 Serum electrolytes
 Urinalysis
 ECG
 Chest X-ray
 Lipid Profile
 HbA1c
 FBS and RBS
 Therapeutics

 Control of Hypertension
Blood Pressure Monitoring
To consider anti-platelet therapy
 Control of Diabetes
Pharmacologic therapy
Annual Eye exam
Foot examination
Lipid profiling
Serum creatinine
 Therapeutics

 Non-pharmacologic
 Diet modification

 Low salt, fat, carbohydrate diet

 Increase physical activity

 Avoid smoking

 Should undergo physical therapy for muscle strengthening