gone in a heartbeat…. identifying data j.e. 23/f, right handed single mother with a live-in...
TRANSCRIPT
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.