Stroke vs MalingeringRianna Leigh R. Salazar, MD

Objective

Discuss ways to differentiate a true neurologic deficit from a patient who is malingering

Case of JIO

18 year oldFemaleCollege studentfrom Bicol

Left sided weakness

Chief Complaint

*RIGHT HANDED

30 minutes prior30 minutes prior

While on ROTC While on ROTC TrainingTraining

Loss of Loss of consciousnessconsciousness

On the way to On the way to TMC-ERTMC-ER

Left-sided Left-sided weaknessweakness

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

Family HistoryBirth History

unknown (adopted)

Personal and Social Historysmoker since September 2013, 10 sticks/day

Occasional alcohol drinker

denies drug use

Athlete (previous track & field varsity)

Review of SystemsGeneral: 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

Physical ExaminationGeneral: 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

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

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

Admitting Impression

Stroke in the young vs Reversible Ischemic Neurologic Deficit

Differential Diagnosis

Migraine

Seizure

Infection

Demyelination

Hypoglycemia

history of history of headacheheadache

no fever, work-up?no fever, work-up?headacheheadache

headache, headache, ROTCROTC last meal? CBG?last meal? CBG?

family history? family history? undiagnosed case?undiagnosed case?

loss of loss of consciousnessconsciousness

constitutional constitutional signs?signs?

tonic clonic? tonic clonic? postictal?postictal?

sensori-motor sensori-motor deficitsdeficits

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

Working Impression

Stroke in the young vs Reversible Ischemic Neurologic Deficit vs Malingering

Greer, S, Chambliss, L and Mackler L, What physical exam techniques are useful to detect malingering? The Journal of Family Medicine 2005: 719-722

PATIENT WAS ABLE TO DO THIS WITH NO SUSPICION OF NONORGANIC CAUSE

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

Stroke in the young vs MalingeringDischarge Diagnosis

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

Stroke vs MalingeringRianna Leigh R. Salazar, MD