General Data

General Data

• DS• 65 year old• Female• Right- handed

Chief Complaint

• “Numbness of the left hand”

History of Present Illness

• One hour PTA, – (+) inward movement and numbness of the

left hand– (-) blurring of vision, palpitations, tremors,

nausea, vomiting, dizziness, sweating– (+) disorientation and confusion– (+) stiff?– Rapid and incoherent speech

History of Present Illness

• At the ER,– Two episodes of generalized tonic- clonic

seizures• lasting 1- 2 minutes • stiffening and jerking of the upper and

lower extremities • head tilted to the right • eyes rolling upward• tongue biting

History of Present Illness

• At the ACSU

– throbbing headache located on the top of her head,(6/10)

– (+) generalized weakness– (-) urinary incontinence, blurring of vision,

nausea or vomiting– (-) memory of what happened

Review of Systems

• General: (-) fever, weight loss

• HEENT: (-) tinnitus, colds• Respiratory: (-) difficulty of breathing, coughing• Cardiovascular: (-) chest pains, orthopnea,

PND• Gastrointestinal: (-) change in bowel

movements

Review of Systems

• Genitourinary: (-) dysuria, frequency• Endocrine: (-) heat or cold intolerance, excess

thirst, excess sweat• Musculoskeletal/ Dermatologic: (+)

dermatoses/ trophic skin changes

Past Medical History

• Illnesses

– Seizure secondary to CVD infarct January 2010

– Angina 2007 – Hypertension – Diabetes mellitus type 2 2000

• (-) Trauma• (-) History of febrile seizures

Past Medical History

• Surgeries: None• Hospitalization: January 2010• Allergies: None

Past Medical History

• Ob- gyne– G3P3(3003) – LMP 55 years old– (+) OCP use for 6 months– (-) hormone replacement therapy– (+) preeclampsia: third pregnancy– (+) blood transfusion: third pregnancy

Medications

• Compliant with:

1) Lantus 40 mg SQ OD

2)Aspirin 75 mg OD

3)ISMN (Imdur) 60 mg durule

4)Bisoprolol 10 mg OD

5)Peridopril 8 mg OD

6)Atorvastatin 20 mg/ tab OD

7) Dipyridamole 200 mg/ tab OD

Family Medical History

• Diabetes• Hypertension• Breast Cancer• Stroke• Cardiovascular disease

Personal and Social History

• Married with three children • Occupation: nurse• Occasional drinker• Non- smoker

Physical Examination

Physical Examination

• Awake, not in cardiorespiratory distress• Height: 165 cm• Weight: 80 kg• BMI = 34• BP = 160/70• HR = 73• RR = 14• T = 36.5OC

Physical Examination

• HEENT– Anicteric sclerae; pink palpebral conjunctiva– No nasal congestion– (-) CLAD, (-) TPC, Non- distended neck veins

• Respiratory– Symmetric chest expansion– Clear breath sounds

Physical Examination• Cardiovascular

– Adynamic precordium– Apex beat at 5th ICS LMCL– Regular rhythm, normal rate– Distinct S1 and S2– (-) Murmurs

• Abdominal– Flabby, soft abdomen– Normoactive bowel sounds– No tenderness

Physical Examination

• Extremities– Full and equal pulses (2+)– (-) edema– Good skin turgor

• Skin– Normal hair and scalp, nails– Trophic skin changes/ dermatoses– No pallor or jaundice

Physical Examination• Neuro examination at the ER:

– Awake, still confused and disoriented, able to follow some verbal commands; GCS 14

– Primary gaze: midline dysconjugate gaze, initially oscillopsia on extreme gaze.

– CN II- pupils are equally reactive to light 3 mm; CN III, IV, VI- EOMs full and equal; CN V brisk corneal reflex; CN VII no asymmetry or weakness; CNXIII intact; CN IX- X (-) dysarthria, dysphagia; CN XI no weakness; CN XII tongue midline.

Physical Examination• Neuro examination at the ER:

– Motor 5/5 on all extremities except for the left upper extremity 4/5. Minimal spasticity on the left. Left arm can lift 30˚.

– Sensory intact. – Supple neck– (-) Babinski reflex– (-) hyper, hyporeflexia

Physical Examination• Neurologic :• MMSE: 28/ 30; GCS 15

– Cranial Nerves• I – Not done• II – Pupils 3mm, equally reactive to light; visual fields full to

confrontation• III, IV, VI – Full EOM’s• V – Corneal reflex not done, sensory- intact bilaterally in all three

divisions for sharp, dull, touch stimuli; motor- temporal and masseter strength intact

• VII – No facial weakness and asymmetry• VIII – Gross hearing intact• IX, X – (+) gag reflex

• Neurologic :

• Cranial Nerves (cont.)• XI- (+) shoulder shrug, head turn, 5/5• XII – tongue at midline

Physical Examination• Neurologic

– Motoro (-) muscle, involuntary movementso 5/5 on all extremities except for left upper extremity (4/5)o Drift on the upper left extremityo DTRs: ++ on bilateral brachioradialis, ankle; (-) Babinski

– Somatico Reactive to touch/pain on all extremities. Temperature sensation

intact bilaterally and symmetrically. Position sense intact bilaterally and symmetrically intact except for left upper extremity

– Cerebellaro No dysmetria, dysdiadochokinesia (RAMs, finger to nose, heel

along shin intact bilaterally)– Supple neck, (-) Brudzinski, Kernig

Differential Diagnoses

Syncope

Rule In Rule OutLoss of consciousness -No precipitating factors

-LOC and GTC movements <15-30 seconds- Loss of postural tone-Rare tongue biting and headache

Transient Ischemic Attack

Acute Psychosis

Neoplastic

Rule In Rule Out

-Family history of cancer -No focal neurologic deficit-No chronic headache which worsens over time-No weight loss, nausea, vomiting, irritability

Infection

Rule In Rule Out

-No fever, nausea, vomiting, irritability-Supple neck, (-) Kernig and Brudzinski

Stroke

Rule In Rule Out

-Headache, confusion, lapse of consciousness-(+) hypertension, diabetes mellitus

-No neurologic deficit-No stroke sequelae

Hypoglycemia

Rule In Rule Out

- Good compliance- Does not skip meals

Migraine

Rule In Rule Out-Talkativenes-Altered consciousness and headache-Unilateral weakness

-Prolonged unilateral headache -Duration of headache can last for hours-Seizure?