Identification Identification Full name:
Full name: Albert Madamba LaboresAlbert Madamba Labores Gender:Gender: MM Age/Birthdate Age/Birthdate: 66 y/o: 66 y/o Race:
Race: FilipinoFilipino Civil Status:Civil Status: MarriedMarried Place of Origin:Place of Origin: not statednot stated OcccupationOcccupation: Manager,: Manager, teacher
teacher Religion:
Religion:Not statedNot stated Literacy Level:Literacy Level: LiterateLiterate Informant:
Informant:“Eldest daughter”“Eldest daughter” Relation to Patient Relation to Patient : Daughter: Daughter Reliability:
Reliability: ExcellentExcellent Chief Complaint:
Chief Complaint: Difficulty in speech productionDifficulty in speech production History of Present Illness
History of Present Illness
Patient was apparently well until 9 months PTC (January 12, 2010)
Patient was apparently well until 9 months PTC (January 12, 2010) in Kuala Lumpur, whenin Kuala Lumpur, when the patient had an acute syncope attack and manifested with unusual speech, wherein he the patient had an acute syncope attack and manifested with unusual speech, wherein he was described as talking “like a Martian” when he talked while mixing words from the was described as talking “like a Martian” when he talked while mixing words from the different languages that he knows. The
different languages that he knows. The patient apparently experienced a headache the nightpatient apparently experienced a headache the night before, which he apparently ignored. After the syncope attack, patient was brought to
before, which he apparently ignored. After the syncope attack, patient was brought to thethe Emergency Room in a nearby hospital and was scheduled for
Emergency Room in a nearby hospital and was scheduled for an MRI which he did not an MRI which he did not take.take. The patient instead went to another clinic for
The patient instead went to another clinic for a checkup, and was referred back to a checkup, and was referred back to thethe hospital with an impression of acute ischemic stroke as based on
hospital with an impression of acute ischemic stroke as based on the patient’s manifestinthe patient’s manifestingg signs and symptoms. Upon
signs and symptoms. Upon admission in the hospital, he admission in the hospital, he was given recombinant tissue-typewas given recombinant tissue-type plasminogen activat
plasminogen activator (rt-PA) and or (rt-PA) and sedation. He was confined to the ICU for sedation. He was confined to the ICU for 5 days and to 5 days and to aa private ward in 6 days, where his
private ward in 6 days, where his status gradually improved. He escaped from the hospitalstatus gradually improved. He escaped from the hospital ahead of his discharge period. At home, the
ahead of his discharge period. At home, the patient continued his medications of Neuroaidepatient continued his medications of Neuroaide 3x/day (a supplement, for
3x/day (a supplement, for adjuvant therapy), Epelim (an anticonvulsant), Januvia (anadjuvant therapy), Epelim (an anticonvulsant), Januvia (an antidiabet
antidiabetic), and an ic), and an unrecalled medicine for hypertension. At this unrecalled medicine for hypertension. At this time, patient still hadtime, patient still had minor problems in speech and understanding people with heavy accents, but he did minor problems in speech and understanding people with heavy accents, but he did notnot present with any motor
present with any motor deficienciesdeficiencies. Patient had . Patient had a dietician which prescribed an appropriatea dietician which prescribed an appropriate diet to control his
diet to control his pre-existing hypertenspre-existing hypertension and diabetes. He stopped taking Neuroaide 2ion and diabetes. He stopped taking Neuroaide 2 months PTC, for
months PTC, for undisclosed reasons.undisclosed reasons. 3 days PTC in the
3 days PTC in the PhilippinesPhilippines, patient experienced sudden onset of difficulty in speech, patient experienced sudden onset of difficulty in speech production again, which occurred after eating a heavy lunch with his relatives. He was production again, which occurred after eating a heavy lunch with his relatives. He was rushed to the Emergency Room
rushed to the Emergency Room of the Medical City. According to the of the Medical City. According to the attending physiciaattending physiciann (Dr. Reyes), workup upon arrival revealed that the patient was awake but had
(Dr. Reyes), workup upon arrival revealed that the patient was awake but had difficultydifficulty following commands, and manifested with right eye deviation, slurring of speech, following commands, and manifested with right eye deviation, slurring of speech, word-finding difficulties, right arm weakness (grade 2/5),
finding difficulties, right arm weakness (grade 2/5), and generalized seizure. Patient was alsoand generalized seizure. Patient was also said to have
said to have difficulty in hearing. Diazepam was administered to difficulty in hearing. Diazepam was administered to the patient, which relievedthe patient, which relieved him of his right
him of his right arm weakness. An MRI was also done, with the results still unknown as arm weakness. An MRI was also done, with the results still unknown as of theof the consult. Other medicine given or diagnostic procedures done to
consult. Other medicine given or diagnostic procedures done to the patient were notthe patient were not disclosed.
disclosed. 1 day PTC, patien1 day PTC, patient was reported to have sligt was reported to have slight improvement in speechht improvement in speech production.
production.
Past Medical History Past Medical History
According to the patient’s daughter, the patient did not
According to the patient’s daughter, the patient did not have any notable childhoodhave any notable childhood illnesses. He had previous cases of gout, laryngitis, bronchitis, and vertigo. He was also illnesses. He had previous cases of gout, laryngitis, bronchitis, and vertigo. He was also confined in a hospital for a
confined in a hospital for a mild heart attack when he was 30. Patient is currently mild heart attack when he was 30. Patient is currently diagnoseddiagnosed with diabetes and hypertension, both treated
with diabetes and hypertension, both treated with medication.with medication. Family History Family History See genogram. See genogram. Additional notes: Additional notes:
Positive family history of hypertension, diabetes, asthma and allergies. Patient is 66 years old. His wife is 70. Their children are aged 41, 36, and 34, respectively.
Personal and Social History
The patient graduated college with a degree in Economics in Ateneo I ntramuros, and has a doctorate. He currently works as a manager in an international company based in Kuala Lumpur, Malaysia, and as a teacher in the Philippines. He frequently flies to and from both countries for his work. He was said to have been a heavy smoker (unknown pack-years) but stopped after his first stroke episode in January. He is also an occasional red wine drinker. Patient denies illegal drug usage. He is suspected to be right-handed, since the right hand was primarily used in writing.
Psycho-socio-religious context
From the history of the patient, it can be ascertained that the patient and his family belongs to the upper socio-economic classes. As such, the choice for the diagnostic and treatment modalities available to the patient is somewhat more flexible. However, the
cost-effectiveness and necessity of the modalities should still be considered so that unnecessary costs may be avoided.
Review of Systems
Given the patient’s difficulties in hearing and speech production, review of systems was not done.
Mini-mental Status Exam (MMSE)
MMSE revealed normal findings in orientation, memory (except short-term memory, which was not tested), language and praxis, reading and following directions, copying, fund of knowledge, abstract thinking, and insight and judgement. It should be noted that most of the questions given for the MMSE were written down for the patient to read, given that he had trouble hearing the questions.
Physical Examination Vital signs:
BP: 150/70 HR: 80 beats/min (normal)
RR: 25 cycles/min (tachypnic) Temp: 36.1⁰C Height: not obtained Weight: not obtained BMI: n/a Overall condition: Patient was not in distress
Stature: appears well; patient is ambulatory, coherent and oriented Neurologic Exam:
CN 1 – not done
CN 2, 3, 4, 6– visual actuity measured at 20/60, eyes soft on tonometry, positive ROR reflex for both eyes, full visual fields on confrontation, pupils equally round and reactive to light (approx. 4 mm in dilataion and 1mm in constriction), accommodation and consensual dilation present, intact extraocular movements
CN 5 – intact sensory; no weakness of masseter and temporal muscles CN 7 – intact sensory; no facial weakness noted
CN 8 - Screening test revealed better sound reception in right ear. Weber’s test revealed sound lateralization in the right ear; Rinne’s test revealed longer bone than air conduction in the left ear (abnormal, may indicate conduction hearing loss) and longer air that bone
conduction in the right ear (normal). Patient had a history of stroke.
CN 9, 10 – Normal palatal elevation, no deviation of uvula noted. Taste sensation tests not done. Normal swallowing. Gag and cough reflexes not elicited.
CN 12 – normal tongue movements; no deviations noted.
Skin: Good skin turgidity, no paleness, discolorations, scars and other unusual skin conditions noted.
HEENT :
Head: unremarkable
Eyes: unremarkable; normal sclera and conjunctiva. Patient claims that he uses glasses. See Neurologic exam for other eye findings.
Ears: No tenderness elicited on palpation. Otoscopy not done. See Neurologic exam for other ear findings.
Nose: unremarkable; rhinoscopy not done. Neck: unremarkable; neck veins not distended
Throat: unremarkable; no masses, lesions or dental carries noted in oral cavity and pharynx. Swallowing was normal. Normal palatal elevation without deviation of uvula.
Anterior chest : not examined Lungs: not examined
Heart : not examined
Upper Extremities: All upper extremities 5/5 on muscle strength grading. Abdomen/Inguinal: not examined
Perineum/Rectal: Digital rectal exam was not done.
Lower extremities: Normal reflexes. Negative for extensor plantar reflex. All lower extremities 5/5 on muscle strength grading.
Pre-workup Discussion
Salient features: Patient presented with acute onset of difficulties in speech, hearing, and right arm weakness with right eye deviation and seizures. Patient can comprehend written or spoken directions. Patient’s hearing and speech somewhat improved on 2nd day of
admission. Weber’s test revealed sound lateralization in the right ear; Rinne’s test revealed longer bone than air conduction in the left ear (abnormal, may indicate conduction hearing loss) and longer air that bone conduction in the right ear (normal). Patient is suspected to be right-handed, since the right hand was primarily used in writing. Patient is in the “elderly” age range (66 years old).
Clinical Impression: Broca’s aphasia, secondary to right middle cerebral artery occlusion resulting in acute ischemic stroke of right hemisphere; suspected right ear sensorineural hearing loss.
Pathophysiology of Clinical Impression:
Ischemic stroke can be caused by a number of factors such as thrombosis or embolism. Given the patient’s long-standing hypertension (which he claims to be treated via medicine although there was no proof of regular medicine-taking), it is highly possible for thrombosis or embolism to occur. Thrombus or emboli deposition in one of the branches of the middle cerebral artery may cause the blockage of blood flow to the brain areas it supplies, resulting in infarction and concomitant neurologic disturbance. If the M2 or M3 branches of the middle cerebral artery supplying the dominant hemisphere are blocked, structures that they supply, such as Broca’s area, may be hypoperfused. This will effectively lead to Broca’s aphasia whose manifestations are consistent with the initial presentation of the patient; namely difficulty in speech production but no disorders in speech or written comprehension.
Normally, aphasia presents if the dominant hemisphere is affected by the infarct. A clue in finding out which hemisphere was affected is to look at the side of eye deviation during the occurrence of a stroke, since the eyes usually deviate to the side of the lesion. Since the patient’s eyes deviated to the right, it is highly probable that the lesion is found in the right
hemisphere; thus indicating that the right middle cerebral artery is the one that was
infarcted. Since the patient presented with aphasia, it is possible therefore for him to belong to the minority of people who are right hemisphere-dominant.
The patient’s hearing difficulty may also imply that part of the hearing center of the brain that is found in the temporal lobe may have been affected as well, resulting in sensorineural hearing loss of the right ear. This is highly possible given the somewhat close proximity of the hearing center to Broca’s area. Although the Weber and Rinne tests done yielded conflicting results to this suspicion, it is highly possible for the patient to have simply misheard or not understand the directions of the tests.
Literature review to support impression:
“Broca’s aphasia, also termed expressive or motor aphasia, describes the ability to comprehend written or spoken language, with nonfluent or impaired expression of either spoken or written language... The infarct responsible for Broca’s aphasia encompasses the insula and frontoparietal operculum... M2 is the segment [of the middle cerebral artery] that runs along the insula, and M3 follows the operculum superior to the insula” (Slater, 2010).
Differential diagnoses:
Disease Rule In Rule Out
Wernicke’s Aphasia Initially presented with difficulty in following commands, initially had inappropriate answers to questions during history-taking
Understands written language; accompanying hearing difficulty may explain inability to follow commands and inappropriate answers
Hypoglycemia History of diabetes (may be due
to not taking medicine or taking too much medicine), presents with possible neuroglycopenic symptoms (shakiness,
confusion, difficulty w/
concentration, weakness) that may manifest as difficulty in speaking
Continuing symptoms despite feeding and (assumingly) appropriate glucose control in hospital
Global Aphasia Initially presented with speech
deficits and seemingly auditory comprehension (in the form of difficulty in following
commands), also difficulties in naming and repetition
Rare occurrence with right hemisphere lesions, rarely occurs without hemiparesis (which patient does not exhibit)
Related psycho-social-religious problems
Given that the patient belongs to a higher socio-economic class, the best diagnostic and treatment modalities available are usually afforded to the patient. However, the necessity and efficacy of the treatment should always be kept in mind to reduce unnecessary costs which could add up in the long run. The propensity of the patient to delay treatment, or escape from the hospital once he feels better even if this is ahead of the prescribed schedule, should be addressed since this could result in treatment failure in the future. Diagnostic Workup
- On arrival of patient to the ER, always start by checking for airway, breathing and circulation status and address these as necessary
-
Once patient is stable, check for possible underlying causes of the stroke via electrocardiography (to check for rhythm disorders that may increase risk for embolism), chest radiography (to check for possible lung Ca metastasis), O2 and blood gas measurements, urinalysis, and blood studies (CBC, electrolyte and glucose values, etc).Imaging studies:
- CT scan is usually used as an initial imaging modality given its relatively lower price, easier accessibility, good resolution, rapid testing time, and sensitivity in determining whether the stroke is ischemic or hemorrhagic in nature. CT scan may also detect presence of blocked cranial vessels (which may appear hyperdense)
- MRI may also be done to clinch the diagnosis of stroke, especially in the first few hours of symptom onset. Diffusion-weighted MRI is recommended for faster testing time and better resolution than CT scan
- Transcranial Doppler ultrasonography may be used as a noninvasive method to check the patency of the major intracranial vessels such as the MCA. Similarly,
carotid duplex ultrasonography may also be used to explore other sources of embolic stroke, and along with Doppler ultrasonography may be used to detect possible sites of stenosis.
Therapeutic Management Definitive management :
- Surgery is usually not done unless a space-occupying lesion is the causative factor for the patient’s symptoms.
Supportive/adjuvant/palliative management :
- For acute stroke, recombinant tissue-type plasminogen activator (rt-PA) is given to lyse the embolus causing the blockage in the cerebral artery affected. Hemorrhagic etiologies should first be ruled out before administering this drug
o Efficacy of the drug depends on how early it was given; studies have shown
that administering the drug within 3 hours of symptom manifestation significantly improves the prognosis of the patient
- For ischemic causes of stroke, the blood pressure may be kept slightly elevated initially to promote adequate blood flow to the brain
- Supportive treatment (fluid replacement, adequate nutrition, etc) should be given to the patient as well
- Medication to treat/maintain pre-existing conditions (such as diabetes and hypertension for the patient) should be continued once patient stabilizes
- Preventive measures such as anticoagulant therapy (ex. aspirin) can be started in order to reduce occurrences of thrombus formation
- Upon discharge, appropriate rehabilitation programs should be provided in order for the patient to be restored as close as possible to his status prior to the stroke
incident. This may include physical, occupational, speech and recreational therapy, depending on what the patient needs.
Management to related psycho-social-religious problem
The patient should be advised regarding staying in the hospital for the entire treatment schedule in order to ensure that his condition will be treated completely. Just because the patient already feels better does not rule out his disease from relapsing or progressing; as such it is important to wait for the doctor’s recommendation for discharge before leaving the hospital.
To prevent future occurrences of embolism and thrombus formation, antiplatelet therapy may be given. Usual drug choices include cyclooxygenase inhibitors such as aspirin,
clopidogrel, or ticlopidine. Anticoagulant therapy may also be given to prevent recurrent or pre-existing thromboembolism; warfarin is usually used for this.
Prognosis
The prognosis of acute ischemic stroke depends on how early it was detected and treated. Studies have revealed that administration of rt-PA within 3 hours of symptom manifestation would usually entail a good prognosis. Any longer than this may result in permanent
neurologic sequelae or, in extreme cases, possibly death.
Sources:
Kasper, D., A. Fauci, D. Longo, E. Braunwald, S. Hauser, and J. J ameson. 2005. Harrison’s Principles of Internal Medicine, 16th Edition. McGraw-Hill Medical Publishing Division.
Kumar, V., A. Abbas, and N. Fausto. 2006. Robbins and Coltran Pathologic Basis of Disease. Elsevier.
Morris, Dexter, M.D. Stroke. Available at:
http://www.emedicinehealth.com/stroke/article_em.htm#Stroke Overview. Last accessed: 30 September 2010.
Slater, Daniel, M.D. Middle Cerebral Artery Stroke. Available at:
http://emedicine.medscape.com/article/323120-overview. Last accessed: 30 September 2010.
