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OPD Case Presentation

OPD Case Presentation. General Data. JB 63/M Married Right handed Bgy Councilor From Imus , Cavite. Chief Complaint. Left-sided weakness. History of Present Illness. 8 days PTC S udden L sided weakness Frontal headache, sharp, VAS 6 Dragging of L leg when walking

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OPD Case Presentation

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  1. OPD Case Presentation

  2. General Data • JB • 63/M • Married • Right handed • Bgy Councilor • From Imus, Cavite

  3. Chief Complaint • Left-sided weakness

  4. History of Present Illness • 8 days PTC • Sudden L sided weakness • Frontal headache, sharp, VAS 6 • Dragging of L leg when walking • L PIP and DIP noted to be fixed in a flexed position • L sided numbness • Nausea • No LOC/change in sensorium/slurring of speech/facial asymmetry • Taken to a local clinic O> BP 140/80 A> mild stroke, given unrecalled meds, advised CT scan but no funds

  5. History of Present Illness • 4 days PTC • Consult at PGH Medicine OPD A> CVD prob infarct R, HTN stage 2 fair control, DM suspect, Obese class 2 P> Simvastatin 40mg qHS, Losartan + HCTZ 50/12.5 • Referred to Rehab OPD • Consult

  6. PMHx • HTN, 2009, maintained on Telmisartan 40mg OD with fair compliance UBP 140/80 HBP 160/90 • FHx • HTN – mother • CVD – siblings, mother • SHx • 24-pack-year smoking history, quit this year • Denies alcohol intake/illicit drug use • Lives in a 2-storey house, used to have a bedroom on 2nd floor but moved to 1st floor since ictus

  7. Physical Examination • Awake, alert, ambulatory, w/ assistance, drags L leg • 120/70 > 60 > 20 > afebrile • AS PC (-) CLAD • ECE CBS (-) c/w • AP DHS NRRR (-) murmurs • Flabby soft nontender • FEP (-) c/e

  8. Neurologic Examination • Cranial nerves • II OD distorted pupil NRTL OS 3mm BRTL • III, IV, VI full EOMs • V good masseter tone, intact sensation V1-3 • VII no facial asymmetry • VIII intact gross hearing • IX, X uvula midline • XI poor shoulder shrug L • XII tongue midline

  9. Neurologic Examination • Motor • R 5/5 • L UE 4/5 LE 3/5 • Sensory • R 100% • L 80% • DTRs • ++ except for L biceps, knee +++ • (+) clonus, R • (-) Babinski • Cerebellar • (-) dysmetria/dysdiadokinesia/nystagmus

  10. Musculoskeletal Examination • Flaccid L UE & LE • Full ROMs • Motor strength as described • Good lying and sitting balance and tolerance • Poor standing balance and tolerance • Transfers • can walk with support • unable to sit from supine position

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