1. UNIVERSITY OF SANTO TOMAS HOSPITAL Clinical Division Department of Neurology and Psychiatry SECTION OF NEUROLOGY

2. General Data Patient: AB Age/Sex: 45/M Status: Married Occupation: Helper/Cook for 20+ years Birthday: 10/25/1964 Race: Filipino Religion: Roman Catholic Address: 006 Brgy San Vicente, Apalit, Pampanga Informant : patient, wife Reliability: 80% good Date of Admission: June 29, 2010

3. Chief Complaint Left sided weakness

4. HPI June 28, at 1430 hrs – drinking alcohol beverage with his co-employees, realized that he could not lift his left hand holding the beer bottle – Also felt heaviness of the left lower extremity. Not accompanied with headache or vomiting. His companions also noticed drooping of the left side of the mouth and slurring of speech.

5. HPI 17-1830 hrs – Patient sought consult at a local clinic. BP was 200/100 and the patient was started with nicardipine and amlodipine. 12 lead ECG and CXR was requested. Advised to transfer to our institution because of better experience hence admission.

6. Review of Systems No weight loss, afebrile, no loss of appetite No skin rashes, itchiness No blurring of vision, no discharge No deafness, no discharge No epistaxis, no discharge No neck stiffness, limitation of movement, masses No dyspnea, shortness of breath, cough, hemoptysis No chest pain, PND, orthopnea, easy fatigability, palpitations No nausea, vomiting, alteration in bowel movement, constipation, diarrhea, hematemesis, hematochezia, melena No frequency, urgency, nocturia, weak stream, intermittency, incomplete emptying No muscle pain, no joint stiffness No heat and cold intolerance No polyuria, polydypsia, polyphagia

7. Personal and Social History Mixed diet Smoker 20 pack/years Drinks 2-3 bottles 3x/week for 20 years No illicit drug use

8. Past Medical History Known Hypertensive since 1990 – No maintenance medications – Normal BP 170/100 – Highest BP 200/100 (-) previous stroke (-) previous surgeries and/or hospitalizations (-) trauma

9. Family History (+) Stroke – father (+) HPN – grandmother, father (+) DM - father

10. Physical Examination BP: 180/100 mmHg PR 107 reg Heart rate 107reg RR 19bpm Temp. 36.5C, WT HT BMI Conscious, coherent and not in cardiorespiratory distress Warm, moist skin, no active dermatoses Pink palpebral conjunctiva, anicteric sclerae Septum midline, turbinates not congested, no nasal discharge Moist buccal mucosa, no oral and palatal lesions, non hyperemic posterior pharyngeal wall, tonsils not enlarged No limitation of neck movement, no palpable cervical lymphadenopathy, thyroid gland not palpable

11. Physical Examination No chest deformities, no intercostal and subcostal retractions, symmetrical chest expansion, clear and equal breath sounds Adynamic precordium, AB at 5 th LICS MCL, S1 > S2 at apex, S2 >S1 at the base, no murmurs Globular abdomen, NABS, soft, non tender, no masses, liver and spleen not palpable No muscle tenderness, swelling, Limitation of movement on left side. Cannot move left extremity No joint swelling, tenderness, Pulses full and equal No cyanosis, edema

12. Neurologic Examination Alert, awake, oriented to time, place and person, can follow commands Cranial nerves No anosmia Pupils 2-3 mm ERTL, (+) direct and consensual light reflexes, fundoscopy: (+) ROR, (-) hemorrhage or papilledema EOM full and equal, no ptosis V1-V3 intact, left, can clench teeth (L) central facial palsy, can raise eyebrows, frown and smile R>L, dysarthria Gross hearing intact, no lateralization on Weber’s and Rinne’s Uvula midline on phonation Can shrug shoulders and turn head side to side against Tongue midline on protrusion

13. Neurologic Examination Motor: Normotonic, (-) tremors, (-) atrophy, (-) fasciculations -MMT: 5/5 on RUE/RLE, 3/5 on LUE/LLE -(+) pronator drift LUE Cerebellar: Can do APST, FTNT and heel to shin test Sensory: No sensory deficit to light touch, pain, temp, vibration Reflexes: DTR (+) patella, ankle on left, the rest ++ – (+) Babinski, left (-) nuchal rigidity

14. Assessment Lacunar Syndrome, R MCA territory probably atherothrombotic in nature NIHSS 4, Hypertension Stage 2

15. Plans (diagnostic) Admit the patient CT SCAN CBC with platelet Na, K, SGPT/SGOT Pt, APTT FBS, Lipid profile Chest x-ray PA, LAT 12 Lead ECG Urinalysis

16. Therapeutic Goals for the patient – Control BP with antihypertensives (add specific anti HPN) – Follow up other probably comorbid factors Diabetes Mellitus type 2 Lipid profile – Refer to rehabilitation medicine 3/5 MMT

17. Discussion What is lacunar syndrome Pics Journal