General Data
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Transcript of General Data
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General Data
• DS• 65 year old• Female• Right- handed
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Chief Complaint
• “Numbness of the left hand”
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History of Present Illness
• One hour PTA, – (+) inward movement and numbness of the
left hand– (-) blurring of vision, palpitations, tremors,
nausea, vomiting, dizziness, sweating– (+) disorientation and confusion– (+) stiff?– Rapid and incoherent speech
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History of Present Illness
• At the ER,– Two episodes of generalized tonic- clonic
seizures• lasting 1- 2 minutes • stiffening and jerking of the upper and
lower extremities • head tilted to the right • eyes rolling upward• tongue biting
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History of Present Illness
• At the ACSU
– throbbing headache located on the top of her head,(6/10)
– (+) generalized weakness– (-) urinary incontinence, blurring of vision,
nausea or vomiting– (-) memory of what happened
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Review of Systems
• General: (-) fever, weight loss
• HEENT: (-) tinnitus, colds• Respiratory: (-) difficulty of breathing, coughing• Cardiovascular: (-) chest pains, orthopnea,
PND• Gastrointestinal: (-) change in bowel
movements
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Review of Systems
• Genitourinary: (-) dysuria, frequency• Endocrine: (-) heat or cold intolerance, excess
thirst, excess sweat• Musculoskeletal/ Dermatologic: (+)
dermatoses/ trophic skin changes
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Past Medical History
• Illnesses
– Seizure secondary to CVD infarct January 2010
– Angina 2007 – Hypertension – Diabetes mellitus type 2 2000
• (-) Trauma• (-) History of febrile seizures
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Past Medical History
• Surgeries: None• Hospitalization: January 2010• Allergies: None
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Past Medical History
• Ob- gyne– G3P3(3003) – LMP 55 years old– (+) OCP use for 6 months– (-) hormone replacement therapy– (+) preeclampsia: third pregnancy– (+) blood transfusion: third pregnancy
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Medications
• Compliant with:
1) Lantus 40 mg SQ OD
2)Aspirin 75 mg OD
3)ISMN (Imdur) 60 mg durule
4)Bisoprolol 10 mg OD
5)Peridopril 8 mg OD
6)Atorvastatin 20 mg/ tab OD
7) Dipyridamole 200 mg/ tab OD
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Family Medical History
• Diabetes• Hypertension• Breast Cancer• Stroke• Cardiovascular disease
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Personal and Social History
• Married with three children • Occupation: nurse• Occasional drinker• Non- smoker
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Physical Examination
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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
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Physical Examination
• HEENT– Anicteric sclerae; pink palpebral conjunctiva– No nasal congestion– (-) CLAD, (-) TPC, Non- distended neck veins
• Respiratory– Symmetric chest expansion– Clear breath sounds
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Physical Examination• Cardiovascular
– Adynamic precordium– Apex beat at 5th ICS LMCL– Regular rhythm, normal rate– Distinct S1 and S2– (-) Murmurs
• Abdominal– Flabby, soft abdomen– Normoactive bowel sounds– No tenderness
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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
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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.
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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
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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
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• Neurologic :
• Cranial Nerves (cont.)• XI- (+) shoulder shrug, head turn, 5/5• XII – tongue at midline
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Physical Examination• Neurologic
– Motoro (-) muscle, involuntary movementso 5/5 on all extremities except for left upper extremity (4/5)o Drift on the upper left extremityo DTRs: ++ on bilateral brachioradialis, ankle; (-) Babinski
– Somatico 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
– Cerebellaro No dysmetria, dysdiadochokinesia (RAMs, finger to nose, heel
along shin intact bilaterally)– Supple neck, (-) Brudzinski, Kernig
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Differential Diagnoses
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Syncope
Rule In Rule OutLoss of consciousness -No precipitating factors
-LOC and GTC movements <15-30 seconds- Loss of postural tone-Rare tongue biting and headache
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Transient Ischemic Attack
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Acute Psychosis
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Neoplastic
Rule In Rule Out
-Family history of cancer -No focal neurologic deficit-No chronic headache which worsens over time-No weight loss, nausea, vomiting, irritability
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Infection
Rule In Rule Out
-No fever, nausea, vomiting, irritability-Supple neck, (-) Kernig and Brudzinski
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Stroke
Rule In Rule Out
-Headache, confusion, lapse of consciousness-(+) hypertension, diabetes mellitus
-No neurologic deficit-No stroke sequelae
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Hypoglycemia
Rule In Rule Out
- Good compliance- Does not skip meals
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Migraine
Rule In Rule Out-Talkativenes-Altered consciousness and headache-Unilateral weakness
-Prolonged unilateral headache -Duration of headache can last for hours-Seizure?