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WITH
RIGHT-SIDED BODY WEAKNESS
Rey Kevin Q. Garcia, Post-Graduate Intern, AUFMC
IDENTIFYING DATA
35 y/o, male
Admitted in AUFMC for the first time last May 12, 2015
Medical student
35 y/o male
S>
1 week PTA:
(+) Numbness over the right arm, right leg and lower right
side of the face
35 y/o male
S>
4 days PTA:
(+) Numbness over the right arm, right leg and lower right
side of the face
35 y/o male
S> (Cont.)
Day of Admission
(+) Decrease in sensation over the right arm, right leg and lower right side
of the face
(+) Stroke/TIA (?) 2014; lateralizing weakness (left) lasting for <24h
CT-scan no abnormalities seen; no residual symptoms
35 y/o male
S> (Cont.)
FAMILY HISTORY
(-) Stroke
PERSONAL/SOCIAL HISTORY
Proclivity for food high in salt, fat and preservatives (e.g. sisig,
tocino)
35 y/o male
O>
Vital Signs: BP- 160 / 110 mmHg; HR- 78 bpm; RR- 20 cpm; T- 36 C
Extremities: Full and equal pulses, full range of motion, brisk capillary
refill
35 y/o male
O> (Cont.)
Neurologic Exam:
Unsatisfactory rapid
supination/pronation test
Right
4/5 7080%
100%
100%
7080%
100%
+
++
5/5 100%
+
+ +
+
+
4/5 7080%
Left
+
+
+
+
5/5 100
%
35 y/o male
Neurologic Exam:
Cranial Nerves
Cranial Nerve
Response
Not assessed
II
III, IV, VI
VII
VIII
IX, X
XI
Approach to Neurologic
Disease
Is there a lesion?
Levelize Supratentorial
Localize Cerebral hemisphere, ACA territory
Lateralize Left
Ischemic vs Hemorrhagic
Stroke
Ischemic Stroke (Infarct)
Consciousness relatively
preserved (variable)
Moderate / no headache
Severe headache
Herniation rare/late
35 y/o male
A>
Initial Impression:
Cerebrovascular Accident, probably infarct, left
cerebral hemisphere
Diabetes Mellitus Type II, Non-insulin requiring
Hypertension Stage II, uncontrolled
35 y/o male
P>
Diagnostics:
CBC
RBS
ECG
Diet: LSLF
IVF: PNSS 1L x 8h
CBC (5/12/2015)
Examination
Result
Reference Range
Hematocrit
0.43
0.41-0.50
Hemoglobin
147
140-175 g/L
Leukocyte count
9.57
4.50-11.00 x
10^9/L
Neutrophils
0.61
0.18-0.70
Lymphocytes
0.32
0.10-0.48
Monocytes
0.06
0.00-0.04
Eosinophils
0.01
0.00-0.03
Platelet
398
150-400 x 10^9/L
Result
Reference Range
Creatinine
1.34
0.79-1.56 mg/dL
Potassium
4.65
3.5-5.50 mmol/L
137.6
135-150 mmol/L
270.36
mg/dL
Sodium
Glucose (RBS)
CT-Scan (5/12/15)
Working Diagnosis
CVA infarct, left corpus callosum; ACA region
r/o Demyelinating Disease (MS)
Diabetes Mellitus Type II, Non-insulin requiring
Hypertension Stage II, uncontrolled
P> (Cont.)
Therapeutics
Rosuvastatin 10 mg/tab OD
Omeprazole (Omevex) 40 mg OD
Problem: Hypertension
Amlodipine 5 mg tab OD
Problem: Diabetes II
HOSPITAL DAY 3