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Stroke vs Malingering

Stroke vs Malingering. Rianna Leigh R. Salazar, MD. Objective. Discuss ways to differentiate a true neurologic deficit from a patient who is malingering. 30 minutes prior While on ROTC Training Loss of consciousness. Case of JIO. On the way to TMC-ER Left-sided weakness.

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Stroke vs Malingering

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  1. Stroke vs Malingering • Rianna Leigh R. Salazar, MD

  2. Objective • Discuss ways to differentiate a true neurologic deficit from a patient who is malingering

  3. 30 minutes prior While on ROTC Training Loss of consciousness Case of JIO On the way to TMC-ER Left-sided weakness Left sided weakness Chief Complaint • 18 year old • Female • College student • from Bicol *RIGHT HANDED

  4. Past Medical History • Syncope (2011-NYC), less than 10 minutes • ECG - normal, sent home with no medications • Occasional palpitations since childhood • no consult • Acid peptic disease • Omeprazole • Headaches since 4 years ago • Paracetamol given, last headache last month

  5. Family HistoryBirth History • unknown (adopted) Personal and Social History • smoker since September 2013, 10 sticks/day • Occasional alcohol drinker • denies drug use • Athlete (previous track & field varsity)

  6. Review of Systems • General: No changes in appetite, No significant weight gain/loss, No changes in general activity, HEADACHE • HEENT: No seizures, no epistaxis, no gum bleeding • Musculoskeletal/Dermatologic: No rashes, no cyanosis, no joint swelling • Respiratory: No difficulty of breathing, no cough, no colds, no hemoptysis • Cardiovascular: No chest pains, no orthopnea • Gastrointestinal: No change in bowel movement, no abdominal pain, no jaundice, no dysphagia • Genitourinary: No frequency, no hematuria

  7. Physical Examination • General: Alert, awake, not in cardiorespiratory distress • Vital Signs: • BP 90/60 HR 54 RR 19 T 37.0°C • Pain scale 7/10 • Essentially normal HEENT, Pulmonary, Cardiovascular, Abdominal, Extremities examination

  8. Physical Examination • Alert, conversant, oriented to 3 spheres, GCS 15 • Cranial Nerves: • I: not assessed • II: pupils 2-3mm EBRTL • III, IV, VI: full range EOM • V1: 60% sensory, Left • V2: 50% sensory, Left • V3: 50% sensory, Left • VII: shallow NLF, Right • VIII: intact gross hearing • IX, X: intact gag and swallowing • XI: moves head left and right, shrugs both shoulders • XII: tongue midline

  9. Physical Examination • DTR: • 2+ all extremities • Motor: • 5/5 right upper and lower extremities • 0/5 left upper and lower extremities • Sensory • 100% right upper and lower extremities • 0% left upper and lower extremities • Cerebellar: intact FTNT, right • Supple neck • Babinski: negative • Negative for clonus

  10. Admitting Impression • Stroke in the young vs Reversible Ischemic Neurologic Deficit

  11. Differential Diagnosis • Migraine • Seizure • Infection • Demyelination • Hypoglycemia family history? undiagnosed case? history of headache loss of consciousness tonic clonic? postictal? headache no fever, work-up? sensori-motor deficits constitutional signs? headache, ROTC last meal? CBG?

  12. At the ER • Admitted under IM, BAT was called • Laboratory tests were normal: CBC, CK Enzymes, PT, aPTT, Na, K, iCal, Mg, SGPT, Total Cholesterol, HDL, LDL, Triglycerides, VLDL, RBS, BUN, Creatinine, ABGs, urinalysis • Cranial MRI: normal • ECG: normal sinus rhythm • Citicholine 500mg IV every 12 hours (adult dose) as neuroprotective • Aspirin 80mg tablet once a day as antiplatelet

  13. Working Impression • Stroke in the young vs Reversible Ischemic Neurologic Deficit vs Malingering

  14. PATIENT WAS ABLE TO DO THIS WITH NO SUSPICION OF NONORGANIC CAUSE Greer, S, Chambliss, L and Mackler L, What physical exam techniques are useful to detect malingering? The Journal of Family Medicine 2005: 719-722

  15. At the PICU (1st hospital day) • 2D echo: normal • Improving neurologic status • Vital signs are stable • Cranial Nerves: • V1: 60% -> 70% • V2: 50% -> 60% • V3: 50% -> 60% • Motor: • 5/5 right upper and lower extremities • 2/5 left upper and lower extremities • Sensory • 100% right upper and lower extremities • 25% left upper and lower extremities • DAMA

  16. Stroke in the young vs Malingering • Discharge Diagnosis

  17. Update • Patient went to school the following Monday with no neurologic deficits • Patient was readmitted under IM service for Non-accidental Ingestion of 30(?) capsules of diphenhydramine, observed for 24 hours in the wards with unremarkable stay

  18. Stroke vs Malingering • Rianna Leigh R. Salazar, MD

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