CASE MANAGEMENT

LEIRA DITH R. CASTRO, MD

PRESENTOR
1ST YEAR IM RESIDENT
 OBJECTIVES
• GENERAL:
• To present a case of a 47 year old, male who presented with headache and vomiting

• SPECIFIC:
• Discuss about the approach in patients presenting with headache and vomiting
• Able to provide differentials for patients with headache and vomiting
• To discuss the diagnosis and management of lateral medullary infarct
• M.A
• 47 / Male
• Filipino
• Matina, Talomo, Davao City
 PROBLEMS

• headache
• Vomiting
 HISTORY OF PRESENT ILLNESS
3 days PTA • Pt was remarkably well as claimed. He recently travelled to
help out with the earthquake victims.

• Noted onset of throbbing headache with generalized

2 days PTA body malaise, nausea and vomiting associated with
intermittent fever (tmax 39.3’C). pt took paracetamol
500mg 1 tab q4 hours which afforded temporary relief.

Night PTA • still noted persistence of fever, headache and

vomiting. Hence this admission.
 PAST MEDICAL HISTORY
• (+) bronchial asthma- salbutamol
• Not known hypertensive, diabetic
• No previous hospital admission
• No previous surgeries
 FAMILY HISTORY AND SOCIAL HISTORY
• HFD: (+) hypertension (+) stroke - sister dx 46 yrs old
• (-) malignancy
• Non smoker
• Non alcoholic beverage drinker
• No known food and drug allergies
• Government employee
• Recently travelled at Makilala
 REVIEW OF SYSTEMS
• Abdominal discomfort
• No cough nor colds
• No LBM
• Dizziness
 PHYSICAL EXAMINATION
• General Appearance:
• Well groomed, lean, Awake, weak looking ,conversant,
• Vital Signs:
• BP-Left arm- 140/100 Right arm- 130/100
• HR 75bpm
• RR 20cpm
• T 35.5°C
• Anthropometric Measures:
• Weight- 72 kgs
• Height- 174 cm
• IBW 66
• BMI: 23. 8
 PHYSICAL EXAMINATION
• Skin: no lesions, no rashes, warm , good turgor
• HEENT and Neck:
• Anicteric sclera
• Pinkish palpebral conjunctiva
• No nasal discharges
• Dry lips / oral mucosa
• No neck vein engorgement
• No facial asymmetry
 PHYSICAL EXAMINATION
• Chest and Lungs:
• Symmetric chest expansion
• Clear breath sounds
• Heart:
– Adynamic precordium
– No heaves nor thrills
– PMI @ 5th ICS, Left MCL
– Regular rate and rhythm
– No murmurs
– S3 and S4 not appreciated
 PHYSICAL EXAMINATION
• Gastrointestinal
• No scars no lesions
• Nondistended abdomen
• Normoactive bowel sounds
• Soft
• Nontender
• No hepatomegaly
• No splenomegaly
 PHYSICAL EXAMINATION

• Genitourinary & Genitals

– (-) kidney punch sign
– Genitals not examined
 PHYSICAL EXAMINATION

• Extremities:
– No edema, no rashes
– Good turgor
– Pulses 2+
– CRT < 2 sec
 PHYSICAL EXAMINATION
• Neurologic
• GCS 15
• Oriented, coherent, responsive, and cooperative, intact immediate, short and
long term memory

• Cranial Nerve Examination:

• CN I : able to smell
• CN II : intact
• CN III, IV, VI : pupils size is smaller 2mm L>R, reactive to light, (+) horizontal
and vertical nystagmus , bilateral
 PHYSICAL EXAMINATION
• CN V: decrease sensory on left face
• CN VII no facial asymmetry. Able to elevate eyebrow, forehead wrinkling, eye closure,
smiling and cheek puff.
• CN VIII able to hear finger rub and whisphered voice
• CN IX, X : (+) uvula deviated to the right, (+) weak gag reflex, pharyngeal elevation to left
• CN XI: able to shrug shoulders
• CN XII: no atrophy , no fasciculation, able to protrude tongue
 PHYSICAL EXAMINATION
• Motor examination: 5/5 on all extremities

• Normoactive reflexes, (-) Babinski

• Coordination examination: (-) dysdiadokinesia(+) dysmetria (+)Oscillations of left arm and

leg on raising

• (-) brudzinkis and kernigs sign

Cerebellar: (+) DYSMETRIA , heel to shin test, can perform rapid
alternating movements,
(+) Romberg’s test
REFLEX

MOTOR
●Good muscle tone, no tremors, no fasciculations,
●Motor strength:
● 5/5 5/5

5/5 5/5

SENSORY
● Sensation to pain and temperature decrease on the right side ,
(+) stereognosis, (+) graphesthesia
 SALIENT FEATURES:
• male Physical exam
• recently travelled
-Elevated BP
• headache
-horizontal nystagmus
• nausea and vomiting
-weak gag reflex
• dysphagia -dysmetria left
• intermittent fever (tmax 39.3’C) -Sensory deficit right arm
• generalized body malaise -dysmetria,left
• No seizure -Oscillations of left arm and leg on
raising
Left arm weakness No rashes
- Brudzinkis and kernigs
What could have been the cause?
• 47/m headache, vomiting, fever

Where is the location of lesion?

 47/m headache, vomiting, fever

Infectious Non-infectious
Viral
encephalitis

bacterial Cerebral vascular Connective Tissue

Viral
disease disorders

meningitis
SLE
encephalitis
 IMPRESSION:
Viral encephalitis

 … fever
 … horizontal nystagmus
 … headache
 …weak gag reflex
 Day 0- 4th HOSPITAL DAY

(-) headache
S (-) vomiting
(+) dizziness
(+) involuntary eye movement
(+)Weakness on left arm
(+) new onset of tinnitus, right
(+) numbness of left side of face
(+) no sweat on left side of face
(+)imbalance upright standing and walk
 Day 0- 4th HOSPITAL DAY

Awake, alert, afebrile, NIRD

o • HEENT: Neck: no neck vein distention, dry lips n tongue (+)
BP 140-170
70-110
HR 72- 84
ngt in place
RR 20-24
• C/L: ECE, clear breath sounds,(-) wheezes Temp 36.7
SaO2  98%
• CVS: AP, DHS, (-) pericardial friction rub
• ABD: soft nabs nontnder
• Ext: no edema, no rashes, erythema or warmth
 DAY 0- 4TH HOSPITAL DAY

• CNS: GCS 15, oriented, intact memory

• (+) horizontal nystagmus , bilateral
• no facial asymmetry
• (+) smaller pupil size left >right
• (+) uvula deviated Right
• (+) Decrease pharyngeal elevation to left
• (+) left dysmetria
• (+)Oscillations of left arm and leg on raising
• (+) rombergs
Dengue fourplex 11/11/19 Blood 12/2/19 11/17/19
• Dengue IgA negative chemistry
Na 124mmol/L 132mmol/L
• Dengue IgG negative
• Dengue IgM negative k K 3.6 mmol/L 4.3
mmol/L
• Dengue NS1 antigen
 DAY 0 -4TH HOSPITAL DAY
Urinalysis 11/11/19
Crea 97.1(99)umol/L Sua 215.6 umol/L
O Color Dark yellow/ turbid
Bun 7.10 SGPT 131 H Gluc/albumin Neg/ ++
Total ca 2.14 mmol/L Cl 105 mmol/L Ph/spc grav 5.0 / 1.025
Mg 0.99mmol/L Mg 0.80mmol/L Pus cells 16-20
FBS 6.14 mmol/L Phosphorus Rbc 4-6
HBA1c 6.3% 1.20mmol/L Epith cells

Chole 3.21mmol/L HDL 0.74mmol/L

Trigly 1.33mmol/L LDL 1.87mmol/L
VLDL 0.6mmol/L
 CBC RESULTS
11/11 11/11 11/12 11/14 11/17 11/28

Hgb 142 142 124 120 134 142

Wbc 12.8 20.8 10.1 8.3 9.0 7.7

Hct 0.41 0.44 0.36 0.35 0.38 0.38

Plt 175 177 186 249 459 393

Neu 91 88.6 87.1 72.2 68.9 69.7

Urinalysis 11/11/19 11/14/19

Color Dark yellow/ turbid Light yellow/clear

Gluc/albumin Neg/ ++ Neg/neg
Ph/spc grav 5.0 / 1.025 6.5/ 1.015
Pus cells 16-20 5-8
Rbc 4-6 0-2
Epith cells Few

Utz wa: normal kub

URINE CS
URINALYSIS
100,000 colonies of Escherichia coli,
ESBL MEROPENEM IG IVTT q8

SENSITIVE: AMPICILLIN,
NITROFURANTOIN ERTAPENEM,
MEROPENEM

RESISTANT:
CEFTRIAXONE
CXR 11/ 2/19 :
no significant chest findings
• MRI:
• Medulla oblangata: the lateral medulla on the left shows low T1, HIGH T2 Signal with fluid
restriction in DW1 and low signal on ADC

• Impression: acute ischemic infarction of the left lateral medulla

• ( lateral medullary syndrome)
IMAGE OF MRI
 DAY 0- 4TH HOSPITAL DAY

• Lateral Medullary syndrome

A • Complicated UTI
 DAY 0- 4TH HOSPITAL DAY

• STAT MRI of the brain

P • Ngt feeding 1700 kcal divided in 6 feedings
• Antiviral medication
• Antiplatelet therapy
• Neuroprotective drug
• PPI
• antibiotic
acyclovir 750mg ivtt q8
• aspirin 80mg 4 tabs now then 1 tab od
• cilostazol 50mg 1 tab bid x 2 doses then increase to 100mg 1 tab bid
• citicoline 1gm q6hours IVTT
• atorvastatin 80mg 1 tab od hs
• Pantoprazole 40mg
• ANA, Anti-DsDNA determination, Protein C , Protein S
• Plans for possible lumbar tap
• For urine gs/cs, for 2decho, for carotid doppler UTZ , hba1c , fbs crea, ALT
• Eye patch on left eye
• Antihypertensive medications started
MANAGEMENT PRIORITIES:
- Provide emergent supportive care (ABC’s)
- Monitor vitals signs, neuro vital signs
- Provide o2 support to maintain Sao2 >94%
- Treat if MAP >130
- Ensure appropriated hydration.

- Emergent diagnostics:
- Cbc, CBG, ECG, CT scan/ MRI
 5th-8th HOSPITAL DAY

S (+) recurrence headache

(+) involuntary eye movement
(+) visual hallucination occasional
(+) dizziness & imbalance upright standing and walk
(+) bp spikes
(+) numbness of right side of face and right arm
 BP150-170/70-110 HR: 72-90’s RR:18-20 spo2 98% t:36-37.3
O Awake, alert, afebrile, not in respiratory distress
• HEENT: no neck vein distention, dry lips n tongue (+) ngt in place
• C/L: ECE, clear breath sounds,(-) wheezes
• CVS: AP, DHS, (-) pericardial friction rub
• ABD: soft nabs nontnder
• Ext: no edema, no rashes, erythema or warmth
 (+) horizontal nystagmus
O (+) weak gag reflex (Decrease pharyngeal elevation to left)
(+) smaller pupil size left >right
(+) left dysmetria
(+) uvula deviated Right
(+) oscillation left hand

•Lateral medullary infarct

A •Complicated UTI
• Blood smear for malarial parasite- no malarial parasite seen in whole thick and thin film
fields

• CXR 11/19/19: right basal hazystreak densities, maybe due to crowding of the vascular
markings and or pneumonic infiltrates
 •IDS: for malarial work up
P •For repeat ct scan
•Referral to hematologist and physical therapist
•For APAS and Factor 8 assay
•Antidepressant
•Centrally acting alpha agonist hypotensive
•Beta blockers
•diuretics
• Norgesic forte prn
• Escitalopram 10mg ½ tab od hs
• Atenolol 50mg 1 tab od
• Indapamide 1.5mg od
 9th-19th HOSPITAL DAY
Improve gag reflex
S No headache
(+) persistent hallucination
Decrease involuntary eye movement
New onset of cough

O BP140-170/70-110 HR: 72-90’s RR:18-20 spo2 98% t:

(-) nystagmus
(+) weak gag reflex (Decrease pharyngeal elevation to left)
(-) left dysmetria
(-) oscillation left hand
(+) rombergs
 LABS
• Anti – nuclear Antibody – negative
• Anti-dsDNA antibody- negative
• Protein C 118% ( N.V. 70-140 )
• Protein S 83% ( N.V. 60-140 )
• Factor assay : APTT
• APAS WORKUP
• PTT patient 28.10seconds (n.v. 25.0-40.0)
• DRVTT >1.20 (n.v. 0.80- 1.20)
• Silica clotting Time 1.17 (1.08-1.21)
• Carotid duplex scan normal
• Normal EEG
• SPUTUM CS 11/14/19
• Moderate growth of Klebsiella pneumoniae ssp. Spneumonia
• Sensitivity : meropenem <0.25
 •Lateral medullary infarct
A •Complicated UTI
•Neurocognitive distrubances 2 to lateral medullary infarct

•Referral to psychiatric evaluation: started ridperidone 2mg ½ tab od

P •EEG
•Carbamazepine
•Rehab started
 • Referral to pulmonologist
P •For repeat cxr, sputum gscs
•d/c carbamazepine
•For Flexible endoscopic testing-
•Macrolide started
•Betahistine bid
 20th-29th HOSPITAL DAY

S Improve gag reflex

Improve gait
No headache
Minimal cough
Slight dizziness
Able to tolerate lugaw
No recurrence hallucination

•
 BP120/80 HR80 RR:18-20 spo2 98% t:
O Ece, minimal rales left baseBP140-170/70-110 HR: 72-90’s RR:18-20 spo2 98%
t:36-37.3
Awake, alert, afebrile, not in respiratory distress
• HEENT: no neck vein distention, dry lips n tongue (+) ngt in place
• C/L: ECE, clear breath sounds,(-) wheezes
• CVS: AP, DHS, (-) pericardial friction rub
• ABD: soft nabs nontnder
• Ext: no edema, no rashes, erythema or warmth
• Flexirhinolaryngoscopy ( Nasal Endoscopy)
• Oropharngeal dysphagia (central dysphagia)
 Cap mr
A •Lateral medullary infarct
•Complicated UTI-resolved

P •Continuous OT and PT
 DISCHARGE
• Ciprofloxacin 500mg 1 tab bid x 3 more days
• Indapamide 1.5 /tab 1 tab once a day
• Losartan 100mg 1 tab once a day
• Citicoline 1gm 1 tab bid
• Atenolol 50mg 1 tab bid
• Atorvastatin 80mg 1 tab od hs
• Betahistine 24mg 1 tab 2x day
• Amlodipine 10mg 1 tab once a day
• Lansoprazole 30mg 1 tab once a day
 FINAL DIAGNOSIS:

Final Diagnosis:

Lateral Medullary Syndrome (Wallenberg, left )

Hypertensive cardiovascular disease

Community acquired pneumonia-moderate risk

Complicated urinary tract infection

 OBJECTIVES
• GENERAL:
• a case of a 47 year old, male who presented with headache and vomiting

• SPECIFIC:
• Discuss about the approach in patients presenting with headache and vomiting
• Able to provide differentials for patients with headache and vomiting
• To discuss the diagnosis and management of lateral medullary infarct