Small Group Discussion: Neurology

emily
RP, 64, F, married, Born-again, from Bulacan, R-handed 09 / 19 / 12 1:00 PM Chief Complaint: Follow-up for stroke. History of Present Illness: Previously had operation, mitral valve replacement, ever since has been taking Coumadin (1999) Coumadin 5 mg daily is the usual dose, protime (INR) is measured regularly Sept 2010, wasnt able to ff.up so protime was not monitored. Naging 7 na yung INR nya. 1 week before sept 15, 2010, had severe abdominal pain, nagstart to have black tarry stools, dizziness and weakness --- brought to SLMC ER Admitted, then after 1 week hospital stay (sept 15?) had a very severe headache --- transferred to ICU; she suffered a stroke She had a comatose Altered sensorium, then LOC When she woke up, cant recognize people, cant understand people, cant talk. Nabulol, di makapagsalita at di maintindihan ang sinasabi. R face nakangiwi, weakness and numbness R arm < R leg CT scan confirmed stroke According to patient, brain lesion was R sided ad it was a vascular occlusion, but when Dr. Damian asked, she said it was a bleed She was transferred 3 times from wards to ICU 14 units of blood was transfused to her during the entire hospital stay Attending physicians had medical conference, because neuro wants to operate on her, drill a hole in her skull, etc... but her cardio doesnt allow it. In the end they just decided to discontinue her Coumadin for 6 months 2D echo, EEG and CT scan to monitor She was discharged after 35 days She was in wheelchair for 3 months regained partial movement in upper body including face, wheelchair bound coz has not yet regained movement in the legs 1 week after discharge had seizure, right hand and forearm. With dizziness and headache. was conscious during the seizure. Attack lasted 5 min, never naulit. She was readmitted for 5 days in the hospital. EEG was done. Since then, shes maintained in leviteracetam. She was also given supplements like calcium, etc but discontinued already CT scan to monitor her brain lesion, 14 times ito, every week until na clear na siya, which was 1 year later. Last CT scan was 2011 Her rehab in outpatient was 1 month, after that rehab was done at home. nagkasessions pa din sya sa ospital apart from sessions at home kasi kelangan ng mga gamit na sa ospital lang meron. Feb this year was her last rehab and her sensory and motor functions already improved Ff up check up every 3 mos in neuro. And every 2mos in cardio. Current meds Coumadin 5 mg daily and leviteracetam 2x daily Past Medical History: Adult Illnesses:

Small Group Discussion: Neurology

Medical. HPN, ever since 1 pregnancy with eclampsia (1972). She was given maintenance meds but she doesnt take it anymore. RHD (1986), diagnosed in PGH. Advised to have valve replacement in heart center. In 1972, prescribed with penadol. Heart enlargement was improved by the drug. 1999 na naoperahan. Surgical. Mitral valve replacement,1999. Due to sever MVP? Done in slmc. Cyst removal in R and L ear lobes (2000s) Obstetric. G5P4 (4-0-1-3). All term and normal vaginal delivery. 1 was aborted. 1 was stillbirth?? Health Maintenance: Adult Immunizations. Screening Tests.
st

Family History: Mother died 65 y/o. With lung CA. Father died 67 y/o. Had DM, sakit sa baga, treated (TB daw ata) Personal and Social History: HS undergrad. Used to work in Magnolia til 18 y/o when she had dyspnea and unable to walk long distances na. Didnt work anymore after marriage. Housewife, she does chores at home. Now she lives in their own house in Bulacan with __________ (sorry di ko na-note). silang mag-asawa na lang ang magkasama sa bahay, pero anak ang nagfafund ng meds nya Diet composed of rice,vegetables (except green leafy veggies, which are not allowed kasi may vitamin K, baka magbleed sya?), fish. Seldom lang meat. Veggies lang na ususal ay carrots, squash etc. Fond of salty foods. 1 cup of coffee daily. Not smoking or illicit drug use. Occasionally drinks red wine ROS (positives only): Dizziness Eye itchiness, relived by eye drops. Wearing new eyeglasses (I guess nag-iba ang grado nya) Colds, relieved spontaneously Dentures, taas lang Sometimes parang may hangin ang pandinig. Relieve by valsalva Chest pain sometimes, left side Shortness of breath when climbing stairs Knee pain, both sides, relieved by Catinco? Not diagnosed Easy bruisability Sometimes forgets things Physical Examination: Vital Signs: RR: HR: BP:

Small Group Discussion: Neurology

HEENT: Head. Eyes. Ears.. Nose. Mouth/Throat. Lungs: Cardiovascular: S1>S2 apex, S2>S1 base. Systolic crescendo murmur (grade IV) heard on all auscultatory sites, lodest at the apex. Neurologic Examination: Mental status. MMSE 26/30. Orientation 10/10 pts, immediate and short term recall 5/6 pts. Attention and calculation : serial 5s 5/5 pts, spelling 2/5 pts. Naming 2/2 and repetition 1/1. No ideomotor and ideational apraxia. Reading, writing, copying intact. Cranial Nerves. I: Intact. II/III: Visual field not tested. Direct and consensual pupillary reflexes intact III/IV/VI: Frontal gaze midline. EOM movements intact. V (Sensory): intact V (Motor): Temporal and masseter muscles have good symmetric contraction. VII. Facial expressions are symmetrical. VIII: Not done IX/X: No dysphonia, dysarthria, or hoarseness. XI: Able to turn head both sides. Neck and shoulder muscle strength 5/5. XII: Able to protrude tongue and retract tongue Somatosensory: Pain and light touch sensation intact. Vibration and proprioception intact Motor: NO atrophy. Tone normal. Strength of right upper limb muscles is 5/5, expect wrist 3-4/5 and on the left 5/5. Strength of both leg muscles is 5/5. NO abnormal gait. Biceps Triceps Brachoradialis Knee Ankle Babinski -

Right Left DTR: Patient asked if this could be skipped because she easily bruises

Cerebellar Function: Not tested Romberg Negative. Able to stand on 1 foot.