Stroke vs Malingering Rianna Leigh R. Salazar, MD

Objective Discuss ways to differentiate a true neurologic deficit from a patient who is malingering

Case of JIO 18 year old Female College student from Bicol Left sided weakness Chief Complaint *RIGHT HANDED 30 minutes prior While on ROTC Training Loss of consciousness On the way to TMC-ER Left-sided weakness

Case of JIO Left sided weakness 30 minutes prior While on ROTC Training Loss of consciousness On the way to TMC-ER Left-sided weakness

Past Medical History Syncope (2011-NYC), less than 10 minutes ECG - normal, sent home with no medications Occasional palpitations since childhood no consult Acid peptic disease Omeprazole Headaches since 4 years ago Paracetamol given, last headache last month

Family History Birth History unknown (adopted) Personal and Social History smoker since September 2013, 10 sticks/day Occasional alcohol drinker denies drug use Athlete (previous track & field varsity)

Review of Systems General: No changes in appetite, No significant weight gain/loss, No changes in general activity, HEADACHE HEENT: No seizures, no epistaxis, no gum bleeding Musculoskeletal/Dermatologic: No rashes, no cyanosis, no joint swelling Respiratory: No difficulty of breathing, no cough, no colds, no hemoptysis Cardiovascular: No chest pains, no orthopnea Gastrointestinal: No change in bowel movement, no abdominal pain, no jaundice, no dysphagia Genitourinary: No frequency, no hematuria

Physical Examination General: Alert, awake, not in cardiorespiratory distress Vital Signs: BP 90/60 HR 54 RR 19 T 37.0°C Pain scale 7/10 Essentially normal HEENT, Pulmonary, Cardiovascular, Abdominal, Extremities examination

Physical Examination Pulmonary: Equal chest expansion, no retractions, clear breath sounds Cardiovascular: Adynamic precordium, no chest deformities, apex beat not displaced, normal heart rate, regular rhythm, good S1 and S2, no murmurs Abdomen: flat, normoactive bowel sounds, non-tender, no masses Extremities: Full and equal pulses, no edema, no cyanosis Hair and Skin:No rashes, no lesions, hair is normal, nails are pink, CRT less than 2 seconds

Physical Examination Alert, conversant, oriented to 3 spheres, GCS 15 Cranial Nerves: I: not assessed II: pupils 2-3mm EBRTL III, IV, VI: full range EOM V1: 60% sensory, Left V2: 50% sensory, Left V3: 50% sensory, Left VII: shallow NLF, Right VIII: intact gross hearing IX, X: intact gag and swallowing XI: moves head left and right, shrugs both shoulders XII: tongue midline

Physical Examination DTR: 2+ all extremities Motor: 5/5 right upper and lower extremities 0/5 left upper and lower extremities Sensory 100% right upper and lower extremities 0% left upper and lower extremities Cerebellar: intact FTNT, right Supple neck Babinski: negative Negative for clonus

Admitting Impression Stroke in the young vs Reversible Ischemic Neurologic Deficit

Differential Diagnosis Migraine Seizure Infection Demyelination Hypoglycemia history of headache no fever, work-up? headache headache, ROTC last meal? CBG? family history? undiagnosed case? loss of consciousness constitutional signs? tonic clonic? postictal? sensori-motor deficits

At the ER Admitted under IM, BAT was called Laboratory tests were normal: CBC, CK Enzymes, PT, aPTT, Na, K, iCal, Mg, SGPT, Total Cholesterol, HDL, LDL, Triglycerides, VLDL, RBS, BUN, Creatinine, ABGs, urinalysis Cranial MRI: normal ECG: normal sinus rhythm Citicholine 500mg IV every 12 hours (adult dose) as neuroprotective Aspirin 80mg tablet once a day as antiplatelet

Working Impression Stroke in the young vs Reversible Ischemic Neurologic Deficit vs Malingering

Greer, S, Chambliss, L and Mackler L, What physical exam techniques are useful to detect malingering? The Journal of Family Medicine 2005: PATIENT WAS ABLE TO DO THIS WITH NO SUSPICION OF NONORGANIC CAUSE

At the PICU (1st hospital day) 2D echo: normal Improving neurologic status Vital signs are stable Cranial Nerves: V1: 60% -> 70% V2: 50% -> 60% V3: 50% -> 60% Motor: 5/5 right upper and lower extremities 2/5 left upper and lower extremities Sensory 100% right upper and lower extremities 25% left upper and lower extremities DAMA

Stroke in the young vs Malingering Discharge Diagnosis

Update Patient went to school the following Monday with no neurologic deficits Patient was readmitted under IM service for Non- accidental Ingestion of 30(?) capsules of diphenhydramine, observed for 24 hours in the wards with unremarkable stay

Stroke vs Malingering Rianna Leigh R. Salazar, MD