Reloj, Jernelyn P. III-B _____________________________________________________________________________ July 9, 2005 Informant: patient and son % Reliability: 70
I. General Data Purisima Garcia, 59 years old, female, married, Catholic, Filipino, unemployed, born on November 2, 1945, presently residing at 1530 Barrio Sta. Maria, Pedro Gil St., Ermita, Manila, nd was admitted for the 2 time in Ospital ng Maynila on June 29, 2005 at 7:35 pm. II. Chief Complaint Dizziness III. HPI 9 years PTA, patient noticed that ants are attracted to her urine. She was then prompted to go to a diagnostic center in San Andres. She could not remember the laboratory tests done on her, however, she recalls that she was diagnosed to have high blood glucose level (she could not recall exact value). She was prescribed to take 1 tablet of Glibenclamide (Euglucon, 5 mg) daily and 2 tablets of Metformin (Glucophage, 500 mg) daily on separate doses. Patient was also diagnosed to have hypertension. She had a blood pressure of 150/100 that time and was given an antihypertensive drug (she could not recall the name), taken sublingually. She was also prescribed to take a maintenance drug (she could not recall the name also), and she failed to comply with it. After a few months, patient transferred to PGH for free check-ups and medications. She could not remember the tests done on her, but recalls that same findings were noted – that she has high blood glucose level (she could not recall exact value) and hypertension. She was instructed to go back after 3 months if her last blood glucose level is normal and after 2 months if it is high. Same medications were prescribed and she religiously followed this regimen. However, she did not comply with her anti-hypertensive medication. Whenever she feels dizzy and suspect hypertension, she would just take an anti-hypertensive drug (she could not recall the name) sublingually. 3 months PTA, patient complained of dizziness. She described it as feeling faint and unsteady, no sense of movement of body or environment. It was accompanied by weakness of both lower extremities. She consulted at OM. She could not recall the tests done on her, but recalls that she was diagnosed to have a high blood glucose level. She was instructed to take her usual hypoglycemic medications. She could not remember if she was also instructed to take an antihypertensive drug. She was allowed to go home that same day. 2 weeks PTA, patient complained again of dizziness and weakness of both lower extremities and went to OM. She was given insulin intravenously. She could not remember if she was given an antihypertensive drug. She was discharged the next day. Few hours PTA, patient complained of dizziness, weakness of both lower extremities, cannot recognize people’s faces, and cannot respond to voice commands. She was sent to OM and was admitted.
IV. PMH Childhood Illness No immunization. Had chicken pox and measles. Adult Illness Medical: No history of allergy to food and drugs. Surgical: 1993, had vaginal bleeding and underwent dilatation and curettage (D&C) at Tondo General Hospital; 1991, had lump in her left breast and underwent breast biopsy. OB/Gyne: G4P3 (3-0-1-3). Menarche at 12, regular menstrual flow, consumed 2 improvised napkin pads, duration of 3 days. Succeeding menses had regular menstrual flow, consumed 2 improvised napkin pads for 3 days. No pain during menstruation. First coitus at 22 y/o. No dyspareunia. 1 sexual partner. Used oral contraceptive pills for 4 years. Underwent tubal ligation in 1996. Psychaitric: None.
V. FH Father died at 78 years old due to heart attack. Mother died at 56 years old due to heart attack. Has 3 brothers and 3 sisters. One brother, 36 years old, has diabetes mellitus. Other siblings are apparently well. Has 1 daughter and 2 sons who are apparently well. (+) Family history of hypertension and diabetes mellitus.
VI. PSH Patient is married for 23 years, has 1 daughter and 2 sons who are healthy and apparently well. Elementary undergraduate. Unemployed. A dressmaker for 11 years. Does not drink alcoholic beverages, does not smoke. Eats thrice a day. Drinks coffee once a day. No regular exercise. House has 1 storey with 2 rooms. Patient lives with husband and 2 sons. House has one comfort room with pour-flush toilet bowl. Water supply comes from Maynilad. Garbage is collected regularly. Neighborhood is not congested.
VII. ROS General: Has weight loss. No easy fatigability, fever, sweats, chills. Skin: No wounds, rashes, itching. Head, Eyes, Ears, Nose, Throat (HEENT): Head: No history of head injury. No pain, trauma. No headache. Eyes: Uses eyeglasses (L)150, (R)200. No pain, diplopia, photopobia, slight lacrimation. Ears: No earache, discharge, tinnitus, vertigo. Nose, sinuses: No difficulty in smelling. No colds, discharge, bleeding. Mouth: Wears dentures (complete). No tootache, mouthsore, gum bleeding. Throat: No inflammation of tonsils. No difficulty in swallowing. Neck: No pain, stiffness, mass.
Breasts: No lumps, pain, discharge. Respiratory: No chestpain, dyspnea, cough, hemoptysis. Cardiovascular: No palpitation, orthopnea, substernal pain. No edema and cyanosis. Gastrointestinal: No abdominal pain, nausea, vomiting, dysphagia. No diarrhea, constipation, hematemesis, melena, hematochezia. Urinary: Has nocturia, polyuria. No dysuria, incontinence, hematuria, urinary retention. Genitalia: No pain, swelling, discharge, ulcers, itching. Gynecologic: Never had pap smear. No vaginal and pelvic infections. No dyspareunia. Hematologic: No anemia, bruising, pallor, bleeding. Musculoskeletal: tenderness. No muscle weakness, pain, cramps, joint swelling, stiffness, backache,
Endocrine: No polydipsia, polyphagia, heat/cold intolerance.
VIII. PE Vital Signs: Wt: 53 kg Ht: 5’1” PR: 91 RR: 25 o T: 37.5 2 BMI: 22.08 kg/m
General Survey: Patient is dressed well and neat. She is conscious of time, place, and person. She is cooperative and cheerful. Skin: Brown complexion. Palms are dry and warm. No scars, sores, bruises, rashes. No clubbing of nails and cyanosis. No tumors and nodules. Head: There is symmetry, normal contour and configuration. No deformities, palpable mass, no tenderness nor lesions. There is equal hair distribution. Hair is fine, dry, black in color. Face: It is symmetrical, no unusual pigmentations, no masses nor scars. Eyes: Patient is able to read up to the 4 line of Jaeger’s at 14 inches. Eyes has no abnormal protrusion. No abnormal thinning or scaling of eyebrows. Eyelids have no abnormal redness, edema, lesions. There is no lid lagging bilaterally. Eyelashes are directed outwards. Sclera is white with regular vascular pattern. Palpebral conjunctiva is pink. Patient is positive for both direct light and consensual papillary reflex. Extraocular muscle movements are intact. Ears: There are no deformities, lumps, ear pain, inflammation. There is cerumen. Tympanic membrane is intact.
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Nose: Patent bilaterally. No discharge. Inferior turbinates are not congested. Mucosa is pink. Nasal septum is in midline. Mouth/Throat: Lips are dry and symmetrical. No unusual pigmentation on lips. Oral mucosa is pink. Tongue is in midline, pink, normal in size and movement. Uvula is centrally located. No swelling of tonsils. Complete dentures. Neck: No pain and limitation of movements. Lymph nodes are not palpable. No abnormal mass and scars. Breasts: Symmetric. No tenderness, mass, unusual pigmentation, dimpling, nipple discharge. Thorax and Lungs: AP diameter is lesser than transverse diameter. It is symmetrical. No scars, striae, visible veins, discoloration. Diaphragmatic mode of respiration. Absence of palpable masses and tenderness. Vocal and tactile fremiti are equal in both lung fields. Resonant sound on all lung fields. Breath sound is vesicular. Cardiovascular: No bulging and depression, no palpable thrills, no bruits, no murmur. PMI is th th located at the 7 intercoastal space left midclavicular line. S1 is heard at the 5 left ICS. S2 is rd heard at the 3 left ICS. Abdomen: No scars, striae, dilated veins, no rashes. Globular abdominal contour, bowel sounds 10 per minute, liver span 7 cm MCL, No tenderness, no mass, spleen not palpable
Neurologic: Cerebral Function Alert, cooperative. Thought processes coherent. Oriented to person, place and time. Speech is spontaneous with normal value. Words spoken clearly and distinctly. Insight and judgement intact. Good remote memory, recent memory and immediate memory. Good calculating ability. Abstract thinking good. Cerebellar Function Finger to nose intact both sides, random alternating movements intact. Romberg’s not performed patient unable to stand. Motor System Muscle strength 2/5, No atrophy, spasticity, rigidity, flaccidity, wasting, contracture, clonus, fasiculations. Sensory System Able to perceive pain, vibration, and light touch on both sides of the body. Intact joint position, stereognosis.
Motor
Sensory
Cranial Nerves CN I: No anosmia CN II: Can read up to the 4 line of Jaeger’s at 14 inches. Can visualize counting fingers of examiner at a distance of 2 feet. No peripheral blindness. Positive direct and consensual reflexes on both eyes. Convergence is intact. CN III, IV, VI: Extraocular muscle movements are all intact. CN V: Able to perceive light touch in both sides of the face, symmetrical temporal and masseter muscle contraction. CN VII: Muscular movements are intact on both sides of face. CN VIII: Can hear the rubbing of fingers at 2 inches away from the ear. No nystagmus. CN IX, X: Positive gag reflex. CN XI: Muscular movements of trapezius and sternocleidomastoid are intact. CN XII: Tongue has no fasciculation, no deviation, movement equal.
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Reflexes Deep Tendon Reflex Biceps Reflex: flexion of the arm at the elbow, 3+ grading Triceps Reflex: extension of the arm at the elbow, 3+ grading Brachioradial Reflex: extension of the hand at the wrist, 3+ grading Pathologic Reflex Babinski reflex: absent
Reflex
IX. Differential Diagnosis
Diseases Migraine Hypoglycemia -
Rule In dizziness alteration of consciousness confusional state motor deficits dizziness confusion
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Hypertension
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dizziness history of DM type 2 dizziness fluctuating mental status dizziness loss of motor function episodes of weakness change in vision, gait or ability to speak or understand
Rule Out nausea photophobia vomiting visual disturbances vertigo syncope fatigue loss of consciousness palpitation increased sweating hunger palpitations easy fatigability fever sepsis
Metabolic Encephalopathy
Transient Ischemic Attack
X. Working Diagnosis: Transient Ischemic Attack (TIA)
XI. Management Immediate management of suspected TIA I. ER evaluation if symptom onset 50% (especially if >80%) a. Obtain carotid arteriogram or MRA b. Arteriogram or MRA confirms >70% stenosis: Surgery c. Arteriogram or MRA suggests 50-69% stenosis i. Consider surgery in lower risk patient ii. Medical therapy in high risk patient
C.
Transcranial ultrasound for posterior circulation Transthoracic echocardiogram Head CT or Head MRI Echocardiogram Holter Monitor
Radiology: Second Line Evaluation Magnetic Resonance Angiography (MRA) Arteriography (gold standard)
II.Urgent outpatient evaluation if >48 hours a. b. c. See labs and radiology above Endarterectomy Indications See Prevention of Ischemic Stroke
Inpatient evaluation criteria 2. 3. Cardioembolic source with Anticoagulation considered a. Acute MI with large wall motion abnormality Large or evolving Cerebrovascular Accident a. Severe neurologic deficit (e.g. dense Hemiplegia) b. TIA symptoms recurring at increasing frequency Vascular or neurosurgery consultation may be required a. High grade Carotid Stenosis suspected b. Possible Subarachnoid Hemorrhage High risk for CVA or TIA complications a. Aspiration Pneumonia
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5.
XII. Prevention Short term prevention after Ischemic Stroke A. Aspirin 325 mg qd (first choice) 1. CVA reduction of 1% with Aspirin by IST trial 2. Effective in acute CVA therapy as well as prevention B. Low dose non-bolus Heparin 1. Efficacy a. No evidence of benefit in CVA evolution b. Less hemorrhage than ASA by IST trial c. CVA reduction 1-2% 2. Dosing: Goal is PTT approximately twice normal a. Dose: 12 u/kg/h (NO bolus, by actual weight) 3. Indications a. Cardioembolic CVA b. Aortic arch atheroma 4. Contraindications a. CT Head shows bleeding b. Endocarditis on native valve thromboembolic CVA Angiotensin Receptor Blocker (ARB) 1. Started on day 1 if Hypertension with Ischemic CVA a. Two BPs >200/100 at 6 to 24 hours post-CVA or b. Two BPs >180/105 at 24 to 36 hours post-CVA 2. Significantly reduced recurrent CVA risk Avoid potentially harmful interventions 1. Heparin drip (Regular dose): Do Not Use a. No significant benefit by IST trial b. Risk of hemorrhage (especially with bolus) 2. Low Molecular Weight Heparin a. Dose dependent CVA reduction by Hong Kong Study b. No benefit and high hemorrhage risk by TOAST study 3. Emergent Anticoagulation not indicated a. Recurrent stroke in first 14 days is only 0.06% b. Can start in first 48 hours after CVA c. Bolus therapy is not indicated 4. Do not lower Blood Pressure aggressively on first day 5. Ibuprofen a. Inactivates Aspirin positive effect b. Unclear if other NSAIDs also reduce benefit
C.
D.
Long term prevention (Primary and Secondary Prevention) E. Anticoagulation after CVA or TIA 1. First-Line options a. Aspirin 50 to 325 mg qd or
2.
3.
b. Clopidogrel (Plavix) if Aspirin intolerant or c. Aspirin 50 mg with Dipyridamole 400 mg (Aggrenox) Other options a. Ticlopidine (Ticlid) b. Dipyridamole 200 mg bid Avoid Warfarin (Coumadin) after nonembolic stroke a. No advantage over Aspirin to prevent recurrent CVA b. Warfarin is indicated in thromboembolic stroke
F.
Other measures 1. Control Hyperlipidemia a. Statin Drugs are preferred (e.g. Lipitor) 2. Control Hypertension to Blood Pressure 30 minutes, >3 days/week 9. Fish intake (1-4 servings per month) a. Lowered Ischemic Stroke risk by 40% 10. Consider Selective Serotonin Reuptake Inhibitor