CASE STUDY WS3

CASE STUDY: STROKE
INITIAL HISTORY:
 76 year old man, slightly confused
 Wife describes symptoms starting 30 minutes ago
 Sudden onset of difficulty getting his mouth to form words; speech is slurred
 Face and mouth numb; tongue feels ‘thick’
 Unable to hold his coffee cup in his right hand
 Right leg weak; needs to hold on to the table to stand
Question 1: What is your differential diagnosis based on the information you have now?
Question 2: What other questions would you like to ask?
ADDITIONAL HISTORY:
 History of essential hypertension
 Has not been taking his thiazide diuretic because it makes him feel ‘bad’
 Was told he has high cholesterol but has not returned to see his primary care provider
 Has experienced several brief spells of right-sided weakness which resolved in a few minutes; thought this was his arm falling asleep
 No head trauma or recent infections
 Family history; mother died of stroke, father died of acute myocardial infarction (AMI)
 Smokes 1 pack/day of cigarettes for the past 30 years
 Sedentary lifestyle
Question 3: Now what do you think?
PHYSICAL EXAMINATION:
 Alert and anxious white male
 Slurred speech, uses appropriate words
 T = 37 C, orally; RR=16; HR = 86 and irregular; B/P 190/120 mmHG (reclining).
HEENT:
 Conjunctiva clear without exudates or lesions
 Fundi without lesions, nicking, or cotton tufts
 Nasal mucosa is pink without drainage
 Oral mucous membranes are moist
 Pharynx is pink without lesions or exudates
Skin, neck:
 Pale with senile lentigines, no lesions or bruises
 No lesions or bruises, no tenting; dry and flaky
 Supple, no lymphadenopathy or thryomegaly
 Bruit auscultated over left carotid artery
Lungs:
 Chest expansion is symmetrical and full
 Diaphragmatic excursion is equal at 4 cm.
 Lung sounds are clear to auscultation
Cardiac:
 Heart sounds: irregular rate and rhythm
 No murmurs, gallops, or clicks
Abdomen:
 Nondistended; bowel sounds are present and not hyperactive
 Liver percusses 2 cm. Below right costal margin but overall 12 cm. in size
 No tenderness or masses; no bruits
Extremities:
 Cool but good capillary refill at 3 seconds
 1 + pitting edema of bilateral ankles
 Radial artery pulses full and equal; anterior pedal pulses diminished but equal
 No clubbing
Neurological:
 Alert and oriented
 Facial droop on right, with loss of nasolabial fold
 Diminished gag reflex
 Strength 3/5 in the right upper extremity and 4/5 in the right lower extremity; 5/5 in the left upper and lower extremities
 Deep tendon reflexes (DTR’s) 1 + on right and 2 + on left
 Sensory intact to touch, no neglect

Question 4: What studies would you initiate now while preparing your interventions?

Question 5: What therapies would you initiate immediately while awaiting results of the lab studies?

LABORATORY:
 EKG; atrial fibrillation
 Serum glucose: 130 mg/dL
 PT = 12.5 seconds; PTT = 28 seconds
 Platelet count 220,000 per cubic mm.
 Head CT scan without contrast media did not reveal evidence of bleeding.

EMERGENCY ROOM COURSE:
 Risks and benefits of thrombolytic therapy are explained to the patient and family
 Patient does not improve neurologically
 B/P improves with labetalol

PHYSICAL EXAMINATION UPDATE:
 Vital signs: B/P = 170/86; HR = 100, irregular
 Neurological exam:
o Alert and oriented
o Follows commands
o Right hemiparesis worsening; strength now 2/5 in both the upper and lower extremities on the right, still normal on the left
o Moderate dysarthria
o Decreased sensation on the right

Question 6: What do you think is happening? Why is the hemiparesis worsening? What does the CT scan mean? Should you continue to treat his hypertension to bring it down to normal?

Question 7: What interventions should be initiated now?

Question 8: Now what should be done and what can the patient expect?

HOSPITAL COURSE:
 Patient does well with digoxin 0.125 mg PO daily for atrial fibrillation. He converts to normal sinus rhythm; P = 82 and regular
 Total cholesterol = 270, HDL = 25, ratio 6.6
 Antihypertensive therapy with an ACE inhibitor is initiated
 Antiplatelet therapy; aspirin 325 mg. PO QD
 HbA1C=6.8%
 He has not smoked while hospitalized
 Cardiac echo was normal (no mural thrombus); carotid Doppler showed < 40% stenosis on right and < 50% on the left with no hemodynamic changes (not a candidate for carotid endarterectomy at this point) Question 9: What instructions and medications should this patient go home with? Question 10: What steps can he take to prevent future attacks and problems? Brashers, V. L. (2006). Clinical applications of pathophysiology: An evidence-based approach. St. Louis, MO: Mosby.