University of the East Ramon Magsaysay Memorial Medical Center Department of Neurosciences Aclan, Beltran Alexis Agbanlog, Nadinne Agoncillo, Karen Elouie Ang Ping, Krista Claudine Ascue, Ronald Alvin

Identifying Data C.B., 60 years old, Filipino male, Roman Catholic, born on June 27. Currently resides at 1950 at Burgos, Pangasinan.

History of Present Illness 8 weeks PTA Sudden onset of headache with no known predisposing factors Described as light headedness and discomfort in the frontal area 7 / 10 intensity Occurred in the evening

History of Present Illness 8 weeks PTA Sudden blurring of vision Hazy but resolved after a few hours Weakness of the middle and ring fingers

History of Present Illness 8 weeks PTA Sought consult on the 3rd day of illness in a nearby hospital Given an impression of mild stroke No CT scan Prescribed with Norvasc, Aspirin, and Statin

History of Present Illness 8 weeks PTA Weakness was noted to be progressive Whole left arm now affected Accompanied by sudden onset of jerking movements Lasted 1 minute No intervention was done

History of Present Illness 7 weeks PTA Consult was again sought Unrecalled anti-convulsants were given Relief was provided Developed progressive dysphagia Both solids and liquids No alleviating and aggravating factors

History of Present Illness 2 weeks PTA Weakness progressed to the left leg Accompanied by jerking movements with a longer duration Consult was sought Underwent CT scan Possible mass was detected Given 2 anti-convulsants

History of Present Illness Patient was confined for 5 days until he was transferred to the UERMMMCI Pertinent Positives: (+) weight loss and weakness

Past Medical History Diagnosed with malaria on 1985

Family History Father died due to cancer of the lungs Mother died due to CVA 4th sibling died of stroke 5th sibling died of cancer of the uterus

Mental Status Examination Orientation: Patient is oriented to all spheres of orientation given minimal verbal cues and prompts; Able to give out personal information correctly Fund of Knowledge: Performed simple mathematical operations correctly

Mental Status Examination Identifying common objects: Able to identify common objects presented such as pen, coin and keys Response to request: Able to perform simple familiar actions upon verbal request Gnostic functions: Intact

Mental Status Examination Practic functions: intact; (-) ideational and ideamotor apraxia; knowledgeable in functions of common objects presented (e.g. brush and ballpen) Fluent speech Good insight and judgment

Mental Status Examination (-) R to L disorientation, finger agnosia, agraphia, acalculia, good attention and concentration, intact immediate, recent and remote memory

Cranial Nerve Examination CN I – intact, can identify test object CN II – intact visual acuity OD 20/200 OS 20/200, No visual field defect (+) direct pupillary reflex, (+) ROR, 4 mm pupil size CN III, IV, VI – brisk reaction to direct/consensual light; full EOMs, (-)Ptosis, primary gaze is midline

Cranial NerveExamination CN V – Intact pain and light touch sensation on both left and right side Good masseter tone, (+) bilateral corneal reflex CN VII – left central facial palsy CN VIII – intact auditory acuity. Able to identify and laterilize stimuli

Cranial Nerve Examination CN IX, X – uvula in midline, intact gag reflex, equal palatal rise CN XI – good right shoulder shrug, poor on left CNXII – tongue in midline with normal strength; able to push the tongue against the tongue depressor superiorly, anteriorly and on both sides; (-) atrophy and fasciculations

Motor Strength Tests Right upper extremities: 5/5 Right lower extremities: 5/5 Left upper 2-3/5 Left lower 4/5

Sensory Tests Right: 100% Left upper- 97% Left lower proximal 97% Distal: 85%

Cerebellar Tests Able to perform finger to nose test with no over and under shooting noted

Reflexes (-) Babinski and Clonus Right Left Biceps Triceps   Triceps Brachioradialis Knee Ankle (-) Babinski and Clonus