Transcript Physical Examination

General Data
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DS
65 year old
Female
Informants: Patient and Husband
Reliability
– Patient 70%
– Husband 80%
• Right- handed
Chief Complaint
• “Numbness of the left hand”
History of Present Illness
• Nine months PTA,
– “pins and needles” sensation; left hand
– one episode of generalized tonic- clonic seizure
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Head tilting to the right
Eyes rolling upward
Stiffening of upper and lower extremities
Tongue biting
Lasting for 1- 2 minutes
– (-) blurring of vision, palpitations, tremors, nausea,
vomiting, dizziness, sweating, urinary incontinence
History of Present Illness
• Admitted in the hospital for 10 days
– CT scan was done
– Discharge summary: Seizure. Two old right
parietal lobe hemorrhagic infarcts. Hypertension.
Diabetes Mellitus Type II. Hypercholesterolemia.
– Medications prescribed:
• Aspirin 75 mg OD
• Dipyridamole 200 mg OD
• Perindopril 8 mg OD
– No memory of what happened
– Patient was able to go back to work
History of Present Illness
• One hour PTA,
– (+) inward movement and numbness of the
left hand
– (+) disorientation and confusion
– (+) stiffness of truncal extremity
– (+) rapid and incoherent speech
History of Present Illness
• At the ER,
– Two episodes of generalized tonic- clonic
seizures similar to the one in January
• 30 minutes apart
History of Present Illness
• At the ACSU
– throbbing headache located on the top of her
head,(6/10)
– (+) generalized weakness
– (-) memory of what happened
Review of Systems
• Neurologic: (-) history of gait imbalance, frequent
headaches
• General: (-) fever, weight loss, easy fatigability
• HEENT: (-) tinnitus, colds, epistaxis, otorrhea
• Respiratory: (-) difficulty of breathing, coughing
• Cardiovascular: (-) chest pains, orthopnea, PND
• Gastrointestinal: (-) change in bowel movements,
abdominal pain, melena, hematochezia
Review of Systems
• Genitourinary: (-) dysuria, frequency,
incontinence, tea colored urine
• Endocrine: (-) heat or cold intolerance, excess
thirst, excess sweat, polydipsia, polyuria
• Musculoskeletal: (-) joint pain and swelling
• Dermatologic: (+) dermatoses/ trophic skin
changes
Past Medical History
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Illnesses
– Angina 2007 maintained on ISMN (Imdur) 60 mg tab
OD
– Hypertension maintained on Bisoprolol 10 mg OD and
Perindopril 8 mg OD
– DM Type II 2000 maintained on Insulin glargine
(Lantus) 40 mg SQ OD
– Hypercholesterolemia 2000 maintained on Atorvastatin
20 mg/ tab OD
(-) Trauma
(-) History of febrile seizures
Past Medical History
• Surgeries: None
• Hospitalization: January 2010
• Allergies: No known allergies
Past Medical History
• Ob- gyne
– G3P3(3003)
– LMP 55 years old
– (+) OCP use for 6 months; 1981 (36 yo)
– (-) hormone replacement therapy
– (+) preeclampsia: third pregnancy
– (+) blood transfusion: third pregnancy
Medications
• Compliant with:
1) Aspirin 75 mg OD
2)Dipyridamole 200 mg/ tab OD
Family Medical History
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Diabetes
Hypertension
Breast Cancer
Stroke
Cardiovascular disease
Personal and Social History
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Married with three children
Occupation: nurse
Occasional drinker
Non- smoker
Physical Examination
Physical Examination
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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
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HEENT
– Anicteric sclerae; pink palpebral conjunctiva
– No nasal congestion
– Moist buccal mucosa
– (-) cervical lymphadenopathy, tonsillopharyngeal congestion,
enlarged thyroid gland
– non- distended neck veins, (-) carotid bruit
• Respiratory
– Symmetric chest expansion
– No retractions
– Clear breath sounds
Physical Examination
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Cardiovascular
– Adynamic precordium
– Apex beat at 5th ICS LMCL
– Regular rhythm, normal rate
– Distinct S1 at apex and S2 at base
– (-) Murmurs
• Abdominal
– Flabby, soft abdomen
– Normoactive bowel sounds
– No tenderness
– No organomegaly
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, confused and disoriented, able to
follow some verbal commands; GCS 14
– Intact cranial nerves
– Intact sensory
– Motor
• Minimal spasticity on the left.
• Left arm can lift 30˚.
– Supple neck
– (+) Babinski reflex, L
Neurologic Examination
• GCS 15
• Mental Status Exam:
– Cooperative towards examiner
– Awake, alert with intact attention span
– Euthymic with appropriate affect
– Non- spontaneous, normoproductive speech
– No perceptual disturbances
– Goal oriented with normal thought content
– Oriented to time, place and person
– Intact memory and calculation
– Good fund of information
– Good insight and judgment
– (-) agnosia, apraxia
Neurologic Examination
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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
• XI- (+) shoulder shrug, head turn, 5/5
• XII – tongue at midline
Physical Examination
• Neurologic
– Motor
o (-) muscle, involuntary movements
o 5/5 on all extremities except for left upper extremity (4/5)
o Drift on the upper left extremity
o DTRs: ++ on bilateral brachioradialis, biceps, triceps, patellar and
ankle; (-) Babinski
– Somatic
o 100% 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 No dysmetria, dysdiadochokinesia (RAMs, finger to nose, heel
along shin intact bilaterally)
– Supple neck, (-) Brudzinski, Kernig's
Initial Impression
• Epileptic seizure
• R/o space- occupying lesion vs. CVD
• Hypertension Stage II
• Diabetes Mellitus Type 2
Differential Diagnoses
Syncope
Rule In
Rule Out
Loss of consciousness
-LOC and GTC movements <15-30
seconds
- Loss of postural tone
-Rare tongue biting and headache
Transient Ischemic Attack
Rule In
-Focal neurologic deficit
-altered consciousness
-Presence of risk factors
Rule Out
- Generalized seizures
Neoplastic
Rule In
-Family history of cancer
-Focal neurologic deficit
Rule Out
-Slowly decreasing level of
consciousness
-No weight loss, nausea, vomiting,
irritability
Infection
Rule In
Seizures
Rule Out
-No fever, nausea, vomiting,
irritability
-Supple neck, (-) Kernig's and
Brudzinski
Stroke
Rule In
-Headache, confusion, lapse of
consciousness
-(+) hypertension, diabetes
mellitus
-(+) Risk factors of hypertension,
diabetes mellitus
Rule Out
Hypoglycemia
Rule In
- seizure
-Confusion
-Headache
-History of insulin use
Rule Out
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Diaphoresis
Pallor
Dizziness
Blurred or double vision
Subarachnoid Hemorrhage
Rule In
- focal neurologic deficit
- altered level of
conciousness/confusional state
Rule Out
-Severe headache at onset, may be
with neck stiffness and vomiting
-Generalized seizures
Initial Imaging Studies
• Head CT
– Wedge shaped I'll defined hypodense focus is seen in
the cortical subcortical region of the right parietal lobe.
– Underlying gyrus and sulci are effaced.
– Patchy hypodensities along the periventricular white
matter of both frontal and parietal lobes are also
noted.
– The rest of the grey-white matter interface is
maintained.
Initial Diagnostics
• CT
– Malacic changes
• CBC
– Hgb 138
– Hct .42
– WBC 8.5
• N .72
• L .24
• M .04
– PC 137
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PT
12.2
INR
0.89
ALT
27.04
BUN
4.48
Creatinine
99.01
Na
137
K
3.9
Lipid Profile (results
to follow)
Initial Management
• Phenytoin
– Loading dose 1gm
– Maintained at 100 mg/cap TID
• Admit to ACSU
– Cardiac, CBG monitoring
– O2 Support, seizure precautions
• Diazepam 5 mg IV
• Ketorolac 30 mg IV then q8 prn for headache
• Continue maintenance medications
Day 1 -3 (Nov 7-9)
S
O
A
P
No recurrence of
seizure
Some difficulty
sleeping
GCS 15
Stable vitals
Clear breath
sounds
NRRR, distinct
S1/S2
Soft abdomen
Post-stroke
seizure
Hypertension
DM 2
Dx:
MRI, MRA, MRV
(Nov 8 )
Tx:
Citicoline
Insulin glulisine
CBG=256 mg/dL
Possible
discharge Nov. 11
Imaging Results
• Cranial MRI
– Wedge-shaped Right inferior parietal corticalsubcortical encephalomalacia, gliosis and
siderosis, presumably sequelae of a previous
water-shed type infarction with hemorrhagic
conversion
– Mild microvascular white matter ischemic
changes on the left centrum semiovale
– Mild central cerebral volume loss
Imaging Results
• MRA: No aneurysm or any significant
stenosis or vascular malformations seen
• MRV: No evident cortical vein or dural
sinus thrombosis
Day 4 (Nov 10)
S
O
Asymptomatic: (-)
palpitations, chest
pain, dizziness
Atrial Fibrillation in Paroxysmal AF
RVR recorded for
3 hours (3:40 am)
Dx: 12L ECG
Tx: Bisoprolol
Cardio referral
Cardio:
BP 116 / 77
HR 52
Sinus bradycardia
Good S1, NRRR
(-) carotid bruit
Paroxysmal AF,
now back in sinus
Hypertension,
stage 2
Dx: 2D ECHO
TFTs
Tx: Amlodipine,
Enoxaparin,
Clonidine,
ISMN
Neuro:
No recurrence of
seizures
MRI/MRA/MRV
Post Gliotic
Seizure
CVD infarct, Right
MCA
Tx: Levetiracetam,
Cholesterol 3.75 (3.4 – 5.2)
HDL 2.33 (high)
LDL 1.39
Triglycerides 0.93
vLDL
0.42
A
P
Sitagliptin
Diagnostics
• ECG: Atrial Fibrillation, RVR
• TFT:
– TSH
– FT3
– FT4
3.01 uIU/mL
2 pg/mL
0.83 ng/dL
• EEG: abnormal EEG due to a focal theta slowing
on the right temporo-parietal occipital region with
wave epileptiform discharges on the right
temporo-occipital region consistent with a focal
cerebral dysfunction and a tendency toward
localization-related seizures at the right
temporo-occipital region
Day 5-7 (Nov 11-13)
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Neuro/Cardio:
Asymptomatic
Comfortable
No recurrence of
AF, seizures
GCS 15
Stable vitals
Clear breath
sounds
NRRR, distinct
S1/S2
Soft abdomen
Post-Gliotic
Seizure
Paroxysmal AF
Hypertension
DM 2
Tx:
d/c Amlodipine,
Enoxaparin
start Diltiazem,
Dabigatran
Cardio: MGH
(11/12); follow up
OPD
Neuro: MGH
(11/13); follow up
OPD
Take Home Medications
Generic Name
Brand Name
Persantine
Dose
200 mg / tab
80 mg / tab
110 mg / tab
BID
OD
BID
Indication
Antiplatelet. Thromboxane and Phosphodiesterase
inhibitor
Antiplatelet. COX inhibitor
Anticoagulant. Direct thrombin II inhibitor
8 mg / tab
60 mg / tab
10 mg / tab
OD
OD
OD
Long-acting ACE inhibitor
Nitro-vasodilator
Selective Beta1 Blocker
Dipyridamole
ASA
Dabigatran
Pradaxa
Perindopril
ISMD
Bisoprolol
Conversyl
Imdur
Concore
Insulin Glargine
Lantus
42 Units
Sitagliptin
Januvia
Diltiazem
Atorvastatin
Co-Amoxiclav
Citicoline
Levetiracetam
Phenytoin
Administration
50 mg
OD, SQ
OD,
pre-breakfast
Antidiabetic. Long-acting insulin analogue
Antidiabetic. Secretagogue, DPP-4 inhibitor
Dilzem
Lipitor
Amoclav
Zynapse
30 mg / tab
20 mg / tab
625 mg / tab
1 g /tab
TID
OD
TID till 11/19
BID
Antiarrhythmic. Calcium Channel blocker
Statin. HMG-CoA reductase, LDL
Antibiotic. Penicillin + Beta-lactamase inhibitor
Nootropic. Psychostimulant
Keppra
Dilantin
500 mg / tab
100 mg / cap
BID
TID
Anticonvulsant
Anticonvulsant, Antiarrhythmic. Sodium channel blocker.
Case Discussion
Pathophysiology Video
Epileptogenesis
• Transformation of a normal neuronal
network into one that is chronically
hyperexcitable
• Trauma, stroke, or infection
• Injury lowers the seizure threshold in the
affected region
• CVD is the number one cause of epilepsy in the elderly
• Oxfordshire Stroke Community Project (OSCP)
– 11.5% of patients with stroke are at risk of developing late-onset poststroke seizures within 5 years
• Naess and colleagues
– 10.5% developed post-stroke seizure over mean follow up
of 5.7 years.
• Hart and colleagues
– recurrence after a first seizure after stroke of 40% in 12
months
Early Onset Seizure
• occurs w/in first two
weeks
• peak 24 hrs after stroke
Late Onset Seizure
• occurs after two weeks of
stroke onset
• peak 6-12 months after
stroke
• associated with the
persistent changes in
neuronal excitability and
gliotic scarring
Seizures and Epilepsy After Ischemic
Stroke
Osvaldo Camilo and Larry B.
Goldstein, 2004
• Cortical location
– Best-characterized risk
factor for early seizures
after ischemic stroke
– Significant risk factor in the
SASS study (HR, 2.09;
95% CI, 1.19 to 3.68; P<0.
01)
• Stroke severity
– Independently associated
with the development of
seizures after ischemic
stroke (HR, 10; 95% CI,
1.16 to 3.82; P<0.02)
Management
• Antiepileptic Drug Therapy
– Goal: completely prevent seizures without
causing untoward side effects
• Treat the underlying conditions
– Reverse the problem and prevent its
recurrence
What is the drug of choice for
adults with generalized-onset tonic–clonic
seizures?
Patient’s Medications UponILAE Treatment Guidelines:
Admission
• Phenytoin (Dilantin)
100mg/cap TID
• Effectiveness-outcome evidence
– Based on RCT efficacy and
effectiveness evidence, CBZ,
LTG, OXC, PB, PHT, TPM, and
VPA are possibly
efficacious/effective as initial
monotherapy for adults with
GTC seizures and may be
considered for initial therapy in
selected situations (level C)
(Glauser, et al. 2006)
Glauser, Tracy, Elinor Ben-Menachem, Blaise Bourgeois, and et. al. "ILAE Treatment Guidelines: Evidencebased Analysis of Antiepileptic Drug Efficacy and Effectiveness as Initial Monotherapy for Epileptic Seizures
and Syndromes." (Internationl League Against Epilepsy) 27, no. 7 (2006): 1094 -1120.
Were these maintenance
medications necessary?
•
Maintenance since
Jan 2010, post
stroke
•
International Stroke Trial (IST, Lancet 1997;349:1569-1581)
– Aspirin treated patients had slightly fewer deaths at 14 days,
significantly fewer recurrent ischemic strokes at 14 days and
no excess of hemorrhagic strokes
•
Dipyridamole for Preventing Stroke and Other Vascular Events
in Patients With Vascular Disease: An Update 2008
– Compared with control, dipyridamole had no clear effect on
vascular death (RR 0.99, 95% CI, 0.87 to 1.12).
– Compared with control, dipyridamole appeared to reduce the
risk of vascular events (RR 0.88, 95% CI, 0.81 to 0.95).
– Routine use of dipyridamole alone as first line antiplatelet
treatment is not supported. The combination of dipyridamole
plus aspirin is associated with a lower risk of further vascular
events than aspirin alone.
– ASA
80mg/tab OD
– Dipyridamole
(Persantine)
200mg/tab
BID
What maintenance medications
does this patient need?
• Home Medications
– Citicoline 1gm/tab BID
– ASA 80 gm/tab OD
– Levetiracetam 500mg
tab BID
– Phenytoin 100mg/cap
TID
Public Health Perspective
The Philippine Scenario
• The statistics are grim
– Less than half of hypertensive patients are
aware that they have high blood pressure
– Only about 1/4th are taking antihypertensive
medications
– Only about 10 percent or less have
adequately controlled high blood pressure.
• Filipinos trivialize Hypertension
Castillo, Dr. Rafael. Stroke Prevention Campaigns. Philippine Daily
Inquirer, 2007.
Complications After Stroke Deprive
Patients of Years of Optimum
Health
• Researchers used data on patients enrolled
in the Complication in Acute Stroke Study
(COMPASS) (n=1254)
• Average DALYs lost due to a stroke was 3.82
• The more complications the patient
experienced, the more DALYs lost
– 1 complication – 1.52 more DALYs lost
– 2 or more complications – 2.69 more DALYs lost
A U.S. National Institutes of Health and the American Heart Association funded study, July 2
AWARENESS CAMPAIGNS
I-Stroke Campaign http://www.otsuka.com.ph/istroke/