Gone in a Heartbeat…

Identifying Data

• J.E. • 23/F, right handed• Single mother• With a live-in partner• Pasig City• Informant: The patient herself with moderate

reliability• Admitted on August 20

Chief Complaint

• Left-sided weakness

History of Present Illness

Sudden generalized sensation of

weakness and numbness of both upper and lower

extremities

Dragged left extremities out of

bed

Left hand suddenly dropped her cell

phone

Realized she can still move her right

(-) Pain, loss of consciousness, headache, vomiting, fever

(+) slurring of speech

(+) facial asymmetry

History of Present Illness

(+) R-sided occipital headache

6/10“Masakit”

Sought consult at Korean acupuncture

clinic

No relief

Persistence of symptoms

A

No convulsionsNo loss of consciousness

No chest pain or palpitationsNo dyspnea or shortness of breath

No orthopnea or paroxysmal nocturnal dyspnea

Review of Systems

• General. No fever. No weight loss.

• Skin. No rashes or other changes.

• Head, Eyes, Ears, Nose, Throat. No history of head injury. Eyes: No blurring of vision. Ears: No difficulty in hearing, no tinnitus, no vertigo. Nose: No difficulty smelling. No nosebleeds. Throat: No gum bleeding, No reported dental pain or problems.

• Neck. No lumps, goiter, or pain. No swollen glands.

• Breasts. No lumps, pain or discharge.

• Respiratory. No cough, hemoptysis. No wheezing, dyspnea.

Review of Systems

• Cardiovascular. (+) Easy fatigability. No chest pain, syncope, or orthopnea.

• Gastrointestinal. Good appetite. No vomiting, dysphagia, heartburn. No change in bowel movement. No pain, jaundice, gallbladder or liver problems.

• Urinary. No Nocturia, frequency. No dysuria, hematuria, flank pain.

• Genital. No vaginal, pelvic infections.

• Peripheral Vascular. No edema or vascularities.

Review of Systems

• Musculoskeletal. No muscle pain, joint pain, nape pain. No joint swelling.

• Psychiatric. No history of depression or treatment for psychiatric disorders.

• Neurologic. No seizures.

• Hematologic. No easy bleeding. No anemia.

• Endocrine. No known thyroid problems or temperature intolerance. No increased sweating. No polyuria or excessive thirst.

Past Medical History

Childhood Illnesses• (+) Mumps, (-) episodes of sore

throat/tonsillitisAdult illnesses• (-) HTN, DM, dyslipidemia, asthma, PTB,

seizures, heart disease • No known allergies, no history of trauma

Past Medical History

Previous Surgeries:• S/P Appendectomy (2010)

Psychiatric history: None

Medications: OCP use for more than a year (Althea), multivitamins

OB History

LMP: July 30, 2011 PMP: June 2011Menarche: 12 years oldInterval: 30-40 daysDuration: 7 days, 4-5 pads. No dysmenorrhea or other symptoms. Coitarche: 18 years old, Age of first pregnancy: 22 years old

Family History

• (+) stroke - Grandmother• (-) HTN, DM, asthma, cancer, heart disease• (-) seizures, aneurysms

Personal Social History

• Non - smoker, occasional alcoholic beverage drinker

• Denies illicit drug use• College student, mother of one• Lives with her Korean partner

Physical Exam at the ERVital Signs. BP 107/59. Heart rate: 110 and regular. Respiratory rate (RR): 18. Temperature (axilla): 37.4 degrees C. Height: 160cm. Weight: 48kg. BMI: 18.7. Pain Scale: 0.

HEENT. Anicteric sclerae, pink palpebral conjunctivae. No exophthalmos, nasal aural discharge, ptosis. No tonsillopharyngeal congestion, cervicolymphadenopathy.

Physical Exam at the ERThorax and Lungs. Equal chest expansion. Clear breath sounds. No wheezing, crackles and rhonchi on auscultation.

Cardiovascular. Strong S1 and S2. Normal rate, regular rhythm. No murmurs.

Abdomen. Flat abdomen. Normoactive bowel sounds. No organomegaly, no pain, tenderness, masses on palpation. No costovertebral angle tenderness.

Physical Exam at the ERGenitalia. Not examined.

Rectal. Not examined.

Extremities. Warm extremities. No edema, cyanosis.

Physical Exam at the ERNeuro. • Awake, alert, coherent to time, place and person. Conversant with some

dysarthria. • Cranial Nerves:• CN I: can identify coffee• CN II: both pupils EBRTL• CN III, IV, VI: primary gaze midline, full EOM, no ptosis

Physical Exam at the ERNeuro. • CN V: 20% sensory deficit to pain, temperature on the left, sluggish

corneals left• CN VII: Shallow left nasolabial fold• CN VIII: Intact gross hearing on both ears, AC>BC on both• CN IX and X: Midline tongue, no fasciculation. • CN XI: No shoulder shrug on the left. • Motor: 0/5 on the left, 5/5 on the right. Sensory: 50% on the left, 100% on

the right. (+) Babinski on the left.