Junsay, Twinkle Mae D.

Section A – Group 10
History #1
Name of the patient: Armando Dela Peña Date of Interview: Jan. 24, 2019
Informant: Rando Dela Peña Date of Submission: Jan. 31, 2019
Reliability: 95% Preceptor: Dr. Jusayan

HISTORY TAKING
A. General Data
A.D., 56 years old, male, married, Filipino, Roman Catholic, born on
November 07, 1962 in Cebu City currently residing at 135 D. West Riverside,
Quezon City, was admitted for the first time in Quezon City General Hospital on
January 19, 2019.
B. Chief Complaint
Numbness of the face and arm
C. History of Present Illness
One year PTA, the patient experienced intermittent pain on nape of the neck.
According to the patient, the pain is heavy in character located at the nuchal area
and is non radiating that occurs suddenly with a scale of 7/10.The pain is relieved
by drinking pineapple juice, medication which is primarily an anti-hypertensive
drug, putting ice pack at the back of the neck and rest.
Few hours PTA, the patient claimed that he went home from work, ate dinner
and washed dishes when he felt headache so he took a nap which afforded no relief
and woke up with a massive headache located at the parietal area and is non
radiating that occurs suddenly with a scale of 10/10. He later felt numbness on the
right side of the face and arm and weakness of the left arm. He took his self-
medicated anti-hypertensive drug. He was unable to speak, grip and walk which
prompted his family to rush him to ER of Quezon City General Hospital at 9pm and
was admitted around 12am with an admitting blood pressure of 200/100.
D. Past medical history
The patient has unrecalled childhood immunizations and no history of any
childhood illnesses. He has no history of previous surgery, accidents or any other
injuries, blood transfusion and has no known allergies to food and drugs.
The patient claims that he has hypertension with a usual blood pressure of
150/90 taken by his neighbor which is a nurse. He was advised to take Calcibloc
50mg an anti-hypertensive drug. He never consulted a physician.
 E. Family medical history
The patient’s father died at the age of 62 due to stroke. His mother died at the
age of 55 due to hypertension. He has 10 siblings and all of them have
hypertension. 4 of them died due to salvage and “kulam”. He has 2 sons and 1
daughter which were healthy as claimed by the patient.
No other heredofamilial diseases such as Cancer, CAD, CHF, RHD, Blood
disorders, Thyroid disorders, kidney disorders, seizure and psychiatric illness was
found.
F. Personal and Social History
The patient finished 2ndyear high school in a public high school in Quezon City.
He previously works as a driver and is now working as a painter 8 hours a day. He
sleeps interruptedly for about 10-12 hours a day. He prefers vegetables and meats
and is not fond of drinking soft drinks or energy drinks. He usually drinks 3-4
bottles of 500ml luke warm mineral water. He is a nonsmoker but drinks alcohol 3
times a week. No substance of abused and stimulants used. He plays basketball
once or twice a month as a form of his exercise.
The patient is living in a compound with a 2 storey cemented type of house
near a creek with his wife and children. The 1 st floor was occupied by his wife and
son with a 1 room, 1 bathroom and a big window. 2 nd floor is occupied by his other
children. Water source for taking a bath and washing is from NAWASA and mineral
water for drinking. Garbage is being collected every Monday, Thursday and
Saturday.

REVIEW OF SYSTEMS
Constitutional symptoms:
(-) fever (-) chills (-) loss of appetite (-) weight loss
Skin:
(-) itchiness (-) excessive dryness (-) pallor (-) jaundice (-) cyanosis (-) erythema
Head:
(-) dizziness (-) vertigo
Eyes:
(-) pain (-) double vision (-) lacrimation (+) excessive blurring of vision
Ears:
(-) earache (-) ear discharge
Nose and Sinuses:
(-) changes in smell (-) nose bleeding (-) nasal discharge (-) pain around paranasal
sinus
Mouth and Throat:
(-) toothache (-) gum bleeding (-) disturbance in taste (-) sore throat (-)
hoarseness
Respiratory:
(-) dyspnea (-) chest pain (-) cough (-) hemoptysis
Cardiovascular:
(-) chest pain (-) palpitations (-) orthopnea
Gastrointestinal:
(-) abdominal pain (-) nausea (-) vomiting (-) dysphagia (-) diarrhea (-)
constipation (-) hematemesis (-) melena (-) hematochezia
Genitourinary:
(-) dysuria (-) urinary frequency (-) hematuria (-) incontinence (-) genital pruritus
(-) urethral discharge
Extremities:
(-) swelling of joints (-) stiffness (-) limitation of movement
Hematologic:
(-) bleeding tendencies (-) easy bruising (-) easy fatigability
Endocrine:
(-) cold intolerance (+) heat intolerance (-) polyuria (-) thyroid enlargement

PHYSICAL EXAMINATION
General Survey
The patient is awake, conscious, and cooperative. He appeared tidy and well-
groomed and has medium body built. No visible gross deformities, with normal
posture and gait. He has slurred speech. Ambulatory, afebrile and not in
cardiopulmonary distress.

Vital signs
BP: 110/70 mmHg
 PR: 78 bpm
RR: 13 bpm
Temp: 36.3ºC (left axilla)

Integumentary
Skin is brown in color, smooth and warm to touch. Tattoo is noted both
arms. Scar measuring from 2-3cm on both legs is noted. Hair is black in color,
smooth and well distributed. Nails are clean with whitish nail beds, with no signs of
cyanosis, no lesions, no clubbing and with normal capillary refill of less than 2
seconds.

Head, Ears, Eyes, Neck and Throat

Cranium
Head is symmetrical and normocephalic, no lumps, no depressions or
tenderness, and temporal artery is not palpable. Hair is dyed, slightly dry and well
distributed. Scalp is slightly movable along the cranium, smooth and dry, and no
lesions.
Face
Face is brown in color, round, asymmetrical facial movement and there is
facial drooping. No involuntary movements, lesions or deformities.
Eyes
Eyebrows are black in color, evenly distributed. Eyelids are symmetrical, no
swelling, and no lesion. Eyelashes are evenly distributed. Sclera is slightly pink,
conjunctiva is pink, cornea has grayish white arc opacity, iris is colored brown, and
pupil has brisk reactions to stimuli with a size of 4mm bilaterally. Visual Acuity is
20/50-1.
Ears
Ears are evenly aligned and symmetrical, no presence of discharge, No
tenderness over the auricles and the mastoid area.
Nose
Nose is symmetrical and blunt. Alar nasi is symmetrical, septum is intact and
in midline, no discharge present, paranasal sinuses are non-tender.
Mouth
Lips are pinkish, moist, and has no lesion. Buccal mucosa are pink, has no
lesion or swelling. Tongue is pink, in the midline and has no lesion, hypertrophy,
and atrophy. Has incomplete set of teeth with no use of dentures. Palate is pink,
has no lesion and has symmetrical elevation. Uvula is located in the midline. Tonsils
are pink, not enlarged, has no secretions and exudates.
Neck
Skin is brown, symmetrical, no lesions or deformities. Muscle tone is normal.
No tenderness upon palpation. Trachea is intact and within midline. Lymph nodes
are non-palpable, areas are non-tender. Thyroid gland is not visibly enlarged.

SPINE and EXTREMITIES

Head and Neck: The patient has no swelling, redness, mal-alignment and crepitus
on tempo-mandibular joint. There is a free range of motio observed. The neck of
the patient is symmetrical, no deformities or abnormal posture present. No spasm
and tenderness noted. Range of motion is normal as to cervical spine flexion,
extension, rotation and lateral bending.
FOREARMS: The forearms are symmetrical and able to perform pronation and
supination without difficulty. There is no atrophy, deformities, swelling or
tenderness.
ELBOW JOINTS: The elbow joints are symmetrical and has full range of motions.
There are no nodules, swelling or tenderness. Circumference above and below the
elbow is 5cm both sides.
UPPER ARM: The upper arms are well developed muscles and no atrophy,
deformities, swelling or tenderness. Decreased sensation on the right upper arm
and right upper forearm.
SHOULDER: The shoulder is symmetrical and has full range of motion. There is no
atrophy, deformities, swelling or tenderness.
THORACO-LUMBAR SPINE: Thoracolumbar spine was not assessed. There is no
mass and tenderness present.
HIP JOINTS: Hip joints have full range of motion, there is no swelling, tenderness,
deformities or misalignment. Iliac crest, iliac tubercle and greater trochanter are
palpable.
THIGH: Thighs are well developed muscles and are symmetrical in shape. There is
no atrophy, deformities, swelling or tenderness. Sensation on both thighs is
present.
KNEE JOINTS: symmetrical and have full range of motion and there are no
effusion, nodules, mass, swelling or tenderness. Circumference above knee is 40
cm both sides while below knee is 34 cm both sides.
LOWER LEG: Well developed muscles and symmetrical in shape. There is no
atrophy, deformities, swelling or tenderness. Sensation on both lower legs is
present.
ANKLE JOINTS: symmetrical with full range of motion. There is no atrophy,
deformities, swelling or tenderness.

CHEST AND LUNGS

Skin is brown, warm to touch, no visible subcutaneous bloodvessels, no

lesions and with a good muscle development. Thoaracic cage is elliptical,
symmetrical and has no bony deformities. No intercostal retraction, bulging,
lagging, narrowing and widening of intercostals spaces. Upon palpation, no
tenderness and masses noted and has symmetrical lung expansion. Only the
anterior lung fields are assessed, normal tactile fremitus on both lung fields,
resonant on all lung fields except on the 3rd-5th left ICS and 7th ICS midclavicular
line. Vesicular breath sounds on all lung fields, no adventitious breath sounds such
as crackles, wheezing, ronchi and friction rub. Negative for bronchophony,egophony
and whispered pectoriloquy.

CARDIOVASCULAR

Precordium is adynamic, no bulging or depression, no intercostal retractions,

no visible masses, no lesions. Apex beat is located at the 5th ICS midclavicular line.
No thrills, heaves or lift. Distinct heart sounds are heard at the apex for S1 and at
the base for S2. No physiologic splitting, murmurs, gallops or extra heart sounds
are heard.

Carotid pulse is strong and bounding, no bruits heard. Jugular veins are not
distended. JVP not assessed. Peripheral pulses in the radial, brachial, carotid areas
are palpable bilaterally but popliteal and dorsalis pedis pulses are weak bilaterally.

ABDOMEN

Upon inspection, the abdomen is flat, symmetrical, without abnormal bulging

or masses. There is no visible hyperpigmentation or hypopigmentation, no scarring,
lesions, and superficial veins. Umbilicus is inverted. No visible pulsations or
peristalsis noted. Abdominal circumference is 90.5 cm.

Upon auscultation, no bruit heard over abdominal aortic vessel, right and left
renal arteries and right and left iliac arteries. Bowel sound is 3 cycles per minute.

Upon palpation, the abdomen is soft with no tenderness or rigidity. No

superficial masses palpated. Liver, spleen and kidney are not palpable.

And upon percussion, liver span is 5cm right midclavicular line. Negative for
ascites and costovertebral angle tenderness. Negative for murphy’s sign, rovsing’s
sign, psoas sign, fluid wave and shifting dullness.
 NEUROLOGIC

Patient is awake, conscious and coherent, oriented to time, person and place,
can identify objects, follow simple and complex commands, and has an intact
remote, recent and immediate memory.

CN I. Olfactory nerve is intact. Patient is able to identify smell using both nostrils.

CN II. Optic nerve is intact. The patient’s visual acuity is 20/50 -1. Visual field is
normal.

CN II, III. Optic and oculomotor nerve is intact. There is equal papillary reaction
to direct and consensual light reflex.

CN III, IV, VI. Oculomotor, trochlear, and abducens nerve are intact. Patient is
able to follow the 6 cardinal gaze.

CN V. Patient was not able to distinguish different sensation on the right side of the
face but was able to demonstrate normal tone and force in the muscle of
mastication.

CN VII. Patient has facial drooping on the right side and weakness in raising the
right eyebrow. He was able to distinguish the taste.

CN VIII. Vestibulocochlear nerve is intact. Able to repeat whispered words, and

able to localize sound

CN IX. Glossopharyngeal nerve is intact. Uvula is in the midline. Gag reflex is

normal.

CN X. Patient has slurred speech. No hoarseness noted.

CN XI. Spinal accessory nerve is intact. Patient is able to shrug the shoulder
against resistance.

CN XII. Hypoglossal is intact. Tongue is in the midline, symmetrical when

protruded. No fasciculation and involuntary movement.

No atrophy, hypertrophy, involuntary movements, and fasciculation noted.

Muscle tone is normal, no spasticity, rigidity or hypotonicity. Muscle strength is 4/5
on the right upper extremity, 5/5 on the left upper extremities, and 5/5 on the
lower extremities, bilaterally.

Patient was able to perform fingers to nose test and heel to shin test
smoothly, bilaterally. Negative for arm and leg dysmetria. Able to perform rapid
alternating pronation and supination, negative for dysdiadochokinesia. Tandem
walking was not assessed because patient cannot stand without support.

Clinical Impression:

Mild cerebrovascular accident/ Mild stroke secondary to uncontrolled hypertension

Salient Features:

Pertinent Positive (+) Pertinent Negative (-)

o 56 years old male o Nausea and vomiting
o Pain and numbness of nape of o Normal BP (baseline)
the neck relieved by drinking
pineapple juice, medications, ice
pack application on his nape and
rest
o Massive headache (10/10)
o Taking self-medicated Calcibloc
50mg irregularly
o Family history of hypertension
o Drinks alcohol 3x a week
o Admitting BP of 200/100mmHg

SUBJECTIVE OBJECTIVE
FINDINGS FINDINGS
o Blurring of vision o Abnormal facie (facial drooping)
o Numbness
o Heat intolerance o Opacities on both eyes

o Slurred speech

o Decreased sensation on the right

side of face and right arm

Differential Diagnosis:
Ischemic Stroke

Rule in: Rule out:

- Sudden numbness/weakness - Sudden and severe headache
of face and arm on one side
of the body
- Slurring of speech
- -High blood pressure

Chronic Subdural Hematoma

Rule in: Rule out:

- Headache - Headache is more prominent on
- Weakness of one side of the the frontotemporal region
face, arm, and leg Drowsiness, inattentiveness and
incoherence of thought – more
prominent

Brain Aneurysm

Rule in: Rule out:

- No blurring or double vision
- Severe Headache
- No pupil dilatation
- Stiff neck - No seizures
- No loss of consciousness
- Numbness of one side of the face
- Weakness
- Difficulty of speaking
Final Diagnosis:

Hemorrhagic Stroke

Discussion:

Cerebrovascular disease is an umbrella term for any brain abnormality

from a vascular pathologic process such as occlusion, alteration in blood flow or
rupture of the vessel.

Stroke or “brain attack” is a sudden onset of focal neurological deficit due

to an underlying vascular pathology. 2 types: Ischemic and Hemorrhagic stroke.
Risk factors:

Nonmodifiable

- older age, male sex, ethnicity (non-white), family history of stroke

Modifiable

- hypertension, diabetes, dyslipidemia, cardiac diseases

- smoking, excess alocohol intake, physical inactivity, obesity, stress

- extracranial and intracranial stenosis

- peripheral arterial disease

HEMORRHAGIC STROKE

According to American Heart Association, hemorrhagic strokes make up about

13 percent of stroke cases. It’s caused by a weakened vessel that ruptures and
bleeds into the surrounding brain. The blood accumulates and compresses the
surrounding brain tissue.

The two types of hemorrhagic strokes are intracerebral (within the brain)
hemorrhage or subarachnoid hemorrhage.

A hemorrhagic stroke occurs when a weakened blood vessel ruptures. Two types
of weakened blood vessels usually cause hemorrhagic stroke: aneurysms and
arteriovenous malformations (AVMs).

Symptoms may include:

 total or limited loss of consciousness

 nausea

 vomiting

 sudden and severe headache

 weakness or numbness in the face, leg, or arm on one side of the body
  seizures

 dizziness

 loss of balance

 problems with speech or swallowing

 confusion or disorientation

Pathophysiology:

Explosive entry of blood into the brain parenchyma

Disrupts neuron

White matter fibre tracts are split

Immediate sessation of neuronal function

Expanding hemorrhage can act as mass lesion

Progression of neuronal deficits

Diagnostics:
 Blood Tests

Complete blood count

This includes a check for your level of platelets, which are cells that help clot
blood. Results can suggest certain conditions that may or may not be associated
with a stroke, such as anemia or an infection.

Clotting time

A pair of tests called PT (prothrombin time) and PTT (partial thromboplastin

time) can check how quickly your blood clots. If it takes too long, it could be a sign
of bleeding problems.

Result: If your blood clots too quickly, your stroke may have been
caused by a clot (ischemic stroke). If your blood clots too slowly, your stroke
may have been caused by bleeding (hemorrhagic stroke)

Imaging Tests

COMPUTERIZED TOMOGRAPHY (CT) SCAN

It is the initial neuroimaging of choice. Highly sensitive in detecting

hemorrhage. It uses a series of X-rays to create a detailed image of your brain. It
shows a hemorrhage, tumor, stroke and other conditions. Dye maybe injected into
your bloodstream to view your blood vessels in your neck and brain in greater
detail (computerized tomography angiography).

CT FINDINGS: (hyperacute phase)

 Gray white matter differential loss

 Insular ribbon sign

 aRtery: dense middle cerebral artery sign

 Lentiform nucleus obscuration

 Sulcal effacement
MAGNETIC RESONANCE IMAGING (MRI)

It uses a strong magnet and radio waves to make pictures of the brain. It
shows brain changes caused by stroke sooner than a CT scan. MRI also can show
any bleeding or blood flow problems. It can rule out other problems such as tumors
that can cause symptoms similar to a stroke.

Disadvantages:

 not sensitive in detecting acute hemorrhage

 more expensive

 longer acquisition time

 less widely available

 contraindicated in patients with metallic implants

CAROTID ULTRASAOUND

A test that uses sound waves to create pictures of your carotid arteries,
which supply blood to your brain. Often used with a CT or MR angiogram, the
carotid ultrasound shows whether plaque has built up in your arteries and is
blocking blood flow to your brain.

CEREBRAL ANGIOGRAM

An X-ray movie of the blood vessels and blood flow through them. A dye is
injected into the veins to show a detailed picture of the blood vessels after a stroke.
A CT angiogram is used with a CT scanner, and a MR angiogram is used with an
MRI.

Trans-cranial Doppler (TCD) ultrasound

A test that uses sound waves to measure blood flow. Also used with a CT or
MR angiogram, the TCD helps find out which artery in your brain is blocked.

Electroencephalogram (EEG)

A test records electrical activity in the brain to be sure your stroke symptoms
are not caused by a seizure. Seizures can cause symptoms like movement problems
and confusion. These can be mistaken for the symptoms of stroke or transient
ischemic attack (TIA).

Electrocardiogram (ECG or EKG)

This test detects and records your heart's electrical activity. It can help your
doctor find out if atrial fibrillation caused the stroke. An ECG can be done during
physical activity to monitor your heart when it is working hard.

Management:

 Lifestyle Modifications eg, smoking cessation, alcohol moderation

 Regularly check BP

 Have regular medical check-ups

 Eat healthy foods

 Have regular exercise

Treatment:

Non Pharmcaologic

Stroke centers and rehabilitation proper rehabilitation of stroke patients include:

 searly physical therapy

 occupational therapy

 speech therapy

Pharmacologic

 Thiazide diuretics, ACE inhibitors, angiotensin receptor blockers,

beta-blockers, and calcium channel blockers

 effectively lower blood pressure during a stroke.

Management of the patient’s blood pressure also reduces
the patient’s risk of another stroke.
 Osmotic agents (mannitol)coupled with inducAed
hyperventilation

 for decreased intracranial pressure