Transcript Physical Examination

Dazed, lost and confused
ANNA SAMANTHA IMPERIAL
MD 070020
History
General Data
 DS
 65 year old
 Female
 April 20, 1945
 Filipino
 Roman Catholic
 Pasig City
 Informant: Herself and her husband, Cipriano
Santiago
 Good reliability: Husband> wife (80% and 70%
respectively)
Chief Complaint
 “Numbness of the left hand”
History of Present Illness
Five hours PTA
( 3 am)
Her husband’s
story
Four hours PTA
(Course in the ER)
• Left hand turned inward and became numb
• No other associated symptoms such as blurring or dimming of
vision, palpitations, tremors, headache, nausea or vomiting
• Patient became confused and disoriented
•
•
•
•
Wife seemed stiff
Wife would talk continuously and rapidly
He would ask her questions; her answers were inconsistent
20 minute ride from their home to TMC ER
• Two episodes of seizure, both lasting 1- 2 minutes described as
stiffening and jerking of the upper and lower extremities with her
head tilted to the right and her eyes rolling upward
• Given two doses of Diazepam 5 mg/IV
• CBC, PT, CBG, creatinine, electrolytes and lipid profile were ordered
as well as CT scan, chest x-ray and ECG
History of Present Illness
 Upon admission, patient found herself in bed at the
Neuro ICU.
throbbing headache located on the top of her head,(6/10)
 abdominal pain in the epigastric area, described as a
burning sensation rising to the chest with a bitter taste
reaching her mouth, (5/10)
 generalized weakness
 no other symptoms such as urinary incontinence,
blurring of vision, nausea or vomiting
 no memory of what happened

Review of Systems
 The rest of the ROS was unremarkable
 (-) fever, cough, colds, orthopnea, PND
Past Medical History
 Illnesses: Seizure. CVD infarct. January 2010 in London;
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angina 2007; hypertension and diabetes mellitus type 2
2000; no history of trauma or febrile sizures
Surgeries: None
Hospitalization: 10 days for her seizure January 2010.
Allergies: None.
Ob- gyne: G3P3(3003) LMP 55 years old, (+) OCP use
for 6 months, (-) hormone replacement therapy, (+)
preeclampsia on the third pregnancy, (+) blood
transfusion also with her third pregnancy
Past Medical History
 Compliant to all medications:
1)
2)
3)
4)
5)
6)
7)
Lantus 40 mg SQ OD
Aspirin 75 mg OD
ISMN (Imdur) 60 mg durule
Bisoprolol 10 mg OD
Peridopril 8 mg OD
Atorvastatin 20 mg/ tab OD
Dipyridamole 200 mg/ tab OD
Family Medical History
 Diabetes
 Hypertension
 Cancer
 Stroke
 Cardiovascular disease
Personal and Social History
 Married with three children
 Occupation: nurse
 Non- 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
BP= 153/68
HR= 61
RR= 18
T= 37OC
Physical Examination

Skin
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Normal nails
Normal hair and scalp
Trophic skin changes/ dermatoses
No lesions or rashes
No pallor or jaundice
 HEENT
 Anicteric sclerae; pink palpebral conjunctiva
 Formed pinna, no tenderness
 No nasal congestion
 (-) CLAD, (-) TPC, Non distended neck veins
Physical Examination
 Respiratory
 Symmetric chest expansion
 Resonant chest walls
 No wheezing, rales, crackles
 Cardiovascular
 Adynamic precordium
 Apex beat at 5th ICS LMCL
 Regular rhythm, normal rate
 Distinct S1 and S2
 (-) Murmurs
Physical Examination
 Abdominal
 Flat abdomen
 Normoactive bowel sounds
 No tenderness on light and deep palpation
 Extremities
 Full and equal pulses (2+)
 (-) edema
 Good turgor
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
 Motor
o
o
o
o
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Somatic
o
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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
Cerebellar
o

(-) muscle, involuntary movements
5/5 on all extremities except for left upper extremity (4/5)
Drift on the upper left extremity
DTRs: ++ on bilateral brachioradialis, ankle; (-) Babinski
No dysmetria, dysdiadochokinesia (RAMs, finger to nose, heel
along shin intact bilaterally)
Supple neck, (-) Brudzinski, Kernig
Salient Features
History:
 “Numbness of the left hand”
 Disorientation and lapse of consciousness
 No other associated symptoms such as blurring or
dimming of vision, palpitations, tremors,
headache, nausea or vomiting, urinary
incontinence before seizure
 Seizure
 (+) headache and weakness after the seizure
episode
Salient Features
History
 ROS: (-) fever, orthopnea, PND
 Past medical history of seizure, DM type 2,
hypertension, angina
 Past family history of stroke, DM type 2,
hypertension, cancer
 No history of trauma
Salient Features
Physical Examination:
 Unremarkable/ Normal physical examination except
for increased blood pressure
 Unremarkable neurologic physical examination
except for:
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4/5 on the upper left extremity (motor)
Drift on the upper left extremity
Position sense is not intact in the upper left extremity
Differentials
Differential
1) Seizure
Rule In
-
2) Stroke
-
-
3) Trauma (bleed/
hemorrhage)
4) Infection
Rule Out
History of seizure
Description of the event
or seizure
Headache, confusion,
lapse of consciousness
Seizures may mask an
ongoing stroke
Headache, confusion,
lapse of consciousness
(+) Risk factors of
hypertension, diabetes
mellitus
-
No neurologic deficit
No stroke sequelae
-
Patient has no history
of trauma
No fever, nausea,
vomiting, irritability
Supple neck, (-)
Kernig and Brudzinski
-
-
Differentials
Differential
5) Neoplastic
Rule In
-
Family history of
cancer
Rule Out
-
6) Metabolic
(hypoglycemia)
7) Syncope
- (+) Loss of
consciousness
-
-
No focal neurologic deficit
No chronic headache which
worsens over time
No weight loss, nausea,
vomiting, irritability
Patient is careful about
taking her medications;
very good compliance
No precipitating factors
such as sweating,
palpitations
LOC <15-30 seconds
Rare tongue biting and
headache
Differentials
Differentials
8) Migraine
Rule In
-Both may manifest with
altered consciousness
and headache
- Maybe characterized by
talkativeness
- Motor: presents
usually with unilateral
weakness
Rule Out
-Usually prolonged
unilateral headache
with associated
features
- Duration of headache
can last for hours
- Usually with a visual
aura
Impression:
EPILEPTIC SEIZURE, GENERAL
CLONIC TONIC TYPE,
R/O SPACE OCCUPYING LESION
VS. BRAIN HEMORRHAGE,
DIABETES MELLITUS TYPE 2,
HYPERTENSION
Lab Results
 CBC:138/0.42/8.50/0.72/0.24/0.04/0/137
 Crea: 99.01 (slightly elevated)
 BUN: 4.48
 Na: 137
 Potassium: 3.90
 Chest x-ray: Normal
 ECG: Normal sinus rhythm
 PT: Control 13.3 Patient 12.2 % Activity 1.24 INR
0.89
Course at the Wards
 (-) recurrences of seizure and no other subjective
complaints
 Medications: phenytoin, citicholine and
continuation of her maintenance medications
 Still for MRI with contrast
Definition
 Seizure- paroxysmal event due to abnormal,
excessive, hypersynchronous discharges from an
aggregate of central nervous system (CNS) neurons
 Epilepsy- recurrent seizures due to a chronic,
underlying process
Definition
 The International League Against Epilepsy (ILAE)
and the International Bureau for Epilepsy (IBE) have
come to consensus definitions for the terms epileptic
seizure and epilepsy. An epileptic seizure is a
transient occurrence of signs and/or symptoms due
to abnormal excessive or synchronous neuronal
activity in the brain. Epilepsy is a disorder of the
brain characterized by an enduring predisposition to
generate epileptic seizures and by the neurobiologic,
cognitive, psychological, and social consequences of
this condition. The definition of epilepsy requires the
occurrence of at least one epileptic seizure.