Anthony Regalado Neurology

Module
Preceptor: Dr. JP Reyes
9/24/2010

Identification
Full name: Albert Madamba Labores Gender: M Age/Birthdate: 66 y/o
Race: Filipino Civil Status: Married Place of Origin: not stated Occcupation: Manager,
teacher
Religion: Not stated Literacy Level: Literate
Informant: “Eldest daughter” Relation to Patient: Daughter
Reliability: Excellent

Chief Complaint: Difficulty in speech production

History of Present Illness

Patient was apparently well until 9 months PTC (January 12, 2010) in Kuala Lumpur, when
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
different languages that he knows. The patient apparently experienced a headache the night
before, which he apparently ignored. After the syncope attack, patient was brought to the
Emergency Room in a nearby hospital and was scheduled for an MRI which he did not take.
The patient instead went to another clinic for a checkup, and was referred back to the
hospital with an impression of acute ischemic stroke as based on the patient’s manifesting
signs and symptoms. Upon admission in the hospital, he was given recombinant tissue-type
plasminogen activator (rt-PA) and sedation. He was confined to the ICU for 5 days and to a
private ward in 6 days, where his status gradually improved. He escaped from the hospital
ahead of his discharge period. At home, the patient continued his medications of Neuroaide
3x/day (a supplement, for adjuvant therapy), Epelim (an anticonvulsant), Januvia (an
antidiabetic), and an unrecalled medicine for hypertension. At this time, patient still had
minor problems in speech and understanding people with heavy accents, but he did not
present with any motor deficiencies. Patient had a dietician which prescribed an appropriate
diet to control his pre-existing hypertension and diabetes. He stopped taking Neuroaide 2
months PTC, for undisclosed reasons.

3 days PTC in the Philippines, patient experienced sudden onset of difficulty in speech
production again, which occurred after eating a heavy lunch with his relatives. He was
rushed to the Emergency Room of the Medical City. According to the attending physician
(Dr. Reyes), workup upon arrival revealed that the patient was awake but had difficulty
following commands, and manifested with right eye deviation, slurring of speech, word-
finding difficulties, right arm weakness (grade 2/5), and generalized seizure. Patient was also
said to have difficulty in hearing. Diazepam was administered to the patient, which relieved
him of his right arm weakness. An MRI was also done, with the results still unknown as of the
consult. Other medicine given or diagnostic procedures done to the patient were not
disclosed. 1 day PTC, patient was reported to have slight improvement in speech
production.

Past Medical History

According to the patient’s daughter, the patient did not have any notable childhood
illnesses. He had previous cases of gout, laryngitis, bronchitis, and vertigo. He was also
confined in a hospital for a mild heart attack when he was 30. Patient is currently diagnosed
with diabetes and hypertension, both treated with medication.

Family History
See genogram.
Additional notes:
Anthony Regalado Neurology
Module
Preceptor: Dr. JP Reyes
9/24/2010

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 Intramuros, 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 11 – Normal sternocleidomastoid and trapezius muscle strength (5/5)
Anthony Regalado Neurology
Module
Preceptor: Dr. JP Reyes
9/24/2010

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
Anthony Regalado Neurology
Module
Preceptor: Dr. JP Reyes
9/24/2010

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
Wernicke’s Aphasia Initially presented with difficulty
in following commands, initially
had inappropriate answers to
questions during history-taking
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
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
Rule Out
Understands written language;
accompanying hearing difficulty
may explain inability to follow
commands and inappropriate
answers
Continuing symptoms despite
feeding and (assumingly)
appropriate glucose control in
hospital
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
Pertinent laboratory and ancillary tests:
Anthony Regalado Neurology
Module
Preceptor: Dr. JP Reyes
9/24/2010

- 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.

Preventive measures
Anthony Regalado Neurology
Module
Preceptor: Dr. JP Reyes
9/24/2010

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. Jameson. 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.