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Stroke Case

Stroke Case. Dr. Edward Warren Chair, Geriatrics Carolinas Campus June 2012. Stroke Case. CC: Right sided weakness and slurred speech

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Stroke Case

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  1. Stroke Case Dr. Edward Warren Chair, Geriatrics Carolinas Campus June 2012

  2. Stroke Case CC: Right sided weakness and slurred speech HCC: This 70 year old white male presents with a sudden onset of right sided upper arm weakness, starting 8 hours ago, associated with slurred and garbled speech, which has worsened in the past few hours. The right arm weakness is severe, the patient is unable to lift the arm or hold things. It started early in the morningduringbreakfast. Family members found him and brought him to the emergency room. The patient is confused and disoriented. Last month, hehad a five minute episode of milder slurred speech and right arm weakness, but this fully resolved and the patient was started on regular strength aspirin for stroke prevention. History: PMH – HTN, peripheral vascular disease (claudication), and Type II diabetes mellitus. His son reports the patient has never had a stroke, heart attack, or bleeding ulcer and has generally been in good health. PSH – Appendectomy years ago. Social – 30 pack year history of smoking, quit smoking 20 years ago, no significant ETOH history, wife deceased, he lives alone at home in the community. Retired Air Force officer. Family history – Father died at 80 from a heart attack, Mother died in a motor vehicle accident, he has four living children, all in good health. ROS: Remarkable for slurred, garbled speech and some confusion – limiting ROS. But, he denies any headache, blurred vision, trouble swallowing, chest pain, difficulty breathing, cough, nausea, vomiting or constipation, or no abdominal pain. No urinary or bowel incontinence and no dysuria. He is able to walk, no falls, only admits to right arm weakness. Family agrees with this. Medications: He takes one regular strength aspirin daily and amlodipine 5mg/benazepril 20 mg daily, glipizideXL 10 mg daily and pentoxiphylline. Allergies: no known drug allergies

  3. Stroke Case: Physical Vitals: BP = 210/94, P = 90, R = 22, Good urine output, weight 200 lbs, Height 5 ft, 11 in Skin – good texture and turgor, no rashes or abnormal moles or growths HENT – head is normocephalic, eyes are non-icteric, gaze noted to be to the left, speech is unintelligible and comprehension is limited and getting worse. Retina – limited visualization, no jugular venous distension (JVD), no cervical adenopathy, mouth is moist, gag and swallow reflex seem intact. No cervical bruits noted. Lungs: Clear to auscultation, no significant rales, rhonchi, nor wheezing Heart: Heart sounds are regular and unremarkable, a grade II/VI systolic ejection murmur noted Abdomen: Soft with normal bowel sounds, no masses, non-tender, no organomegally. No abdominal bruits, Genital-urinary: unremarkable, urine clear, rectal unremarkable, good sphincter tone, stool hemocult negative. Extremities : Right upper extremity is flaccid, no grip strength, good radial pulses but diminished lower extremity dorsal pedal pulse. A right femoral bruit is noted. Laboratory: WBC = 10,000, Hgb = 11.0, Platelets = 200,000, Glucose = 150, Na = 145, BUN = 20, Cr = 1.4, HgbA1C = 7.8 Serum homocysteinelevels are elevated. Total Cholesterol=150, LDL=70

  4. Question 1: Your initial impression is a stroke (cerebral vascular accident or CVA). Based on the clinical impression, which type of stoke is it most likely to be? • Ischemic, anterior cerebral artery distribution • Ischemic, middle cerebral artery distribution • Ischemic, posterior cerebral artery distribution • Ischemic, basilar or vertebral artery distribution • A hemorrhagic stroke

  5. Question 2 In this circumstance, what is the best initial imaging study to order as part of the evaluation of this patient? • CT scan of the head without contrast • CT scan of the head with contrast • MRI scan of the head without contrast • MRI scan of the head with contrast • MRI angiogram of the head

  6. Question 3 You note that the blood pressure in the case toelevated. How fast should the blood pressure be lowered to avoid extending the size of the stroke? • As quick as possible, within minutes • Gradually, over a few hours • Leave the blood pressure until the acute stage has passed, a period of about two weeks

  7. Question 4 What should be your goal blood pressure range for this patient during the acute stroke period ? • As long as symptoms are stable, don’t try to lower the blood pressure • Lower BP a systolic range of 170 to 200 mmHg • Lower BP to a systolic range of 150 to 169 mmHg • Lower BP to a systolic range of 135 to 149 mmHg

  8. Question 5 This patient had some neurologic symptoms the month prior to this acute stroke episode, and was put on anti-platelet therapy. Despite being started on anti-platelet therapy, he still suffered a stroke. Anti-platelet therapy reduces the risk of a future stroke by about how much? • 5% • 15% • 30% • 60% • 90%

  9. Question 6 How many risk factors for a stroke does the patient have? • None • Two • Four • Six

  10. Question 7 Is this particular patient at greater risk of suffering another stroke in the future? • Yes • No

  11. Question 8 If this patient had presented with most severe headache he had ever experienced before, followed by nausea, a stiff neck and loss of consciousness, what would be the most likely diagnosis? • Middle Cerebral Artery Ischemic Stroke • Vertebral Artery Ischemic Stroke • Cerebral venous sinus thrombosis • Hypertensive hemorrhagic stroke • Subarachnoid Hemorrhage

  12. Question 9 If the patient had presented with symptoms of a seizure and focal neurologic symptoms which resolved in 24 hours, what would be the most likely diagnosis? • Transient Ischemic Attach • Unmasked prior stroke • Brain Tumor with cerebral edema • Todd’s Paralysis • Acephalgic migraine

  13. Question 10 For an ischemic stroke, within how many hours from initial onset of symptoms might the patient benefit from thrombolytic therapy? • 3 hours • 4 hours • 5 hours • 6 hours • 7 hours

  14. Answer Key Q1 = B This fits the description of a MCA CVA. Q2 = A Always get a STAT CT without contrast. Q3 = C There is no hurry at this level and the harm is real. Q4 = B This is the correct systolic range. Q5 = C 30% is correct. Q6 = C Four: HTN, claudication, NIDDM, and smoking Hx Q7 = A One stroke leads to another. Q8 = E This fits the description of a subarachnoid hemorrhage. Q9 = D This fits the description of Todd’s paralysis, not a CVA. Q10 = A This is a firm line in most settings, 3 hours.

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