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 27 hours PTA 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 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 (+) slurring of speech (+) facial asymmetry

History of Present Illness A few hours PTA (+) R-sided occipital headache 6/10 “Masakit” (+) R-sided occipital headache 6/10 “Masakit” Sought consult at Korean acupuncture clinic No relief Sought consult at Korean acupuncture clinic No relief Persistence of symptoms A A No convulsions No loss of consciousness No chest pain or palpitations No dyspnea or shortness of breath No orthopnea or paroxysmal nocturnal dyspnea No convulsions No loss of consciousness No chest pain or palpitations No 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/tonsillitis Adult 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, 2011PMP: June 2011 Menarche: 12 years old Interval: days Duration: 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 ER Vital Signs. BP 107/59. Heart rate: 110 and regular. Respiratory rate (RR): 18. Temperature (axilla): 37.4 degrees C. Height: 160cm. Weight: 48kg. BMI: Pain Scale: 0. HEENT. Anicteric sclerae, pink palpebral conjunctivae. No exophthalmos, nasal aural discharge, ptosis. No tonsillopharyngeal congestion, cervicolymphadenopathy.

Physical Exam at the ER Thorax 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 ER Genitalia. Not examined. Rectal. Not examined. Extremities. Warm extremities. No edema, cyanosis.

Physical Exam at the ER Neuro. 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 ER Neuro. 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.