Case #1
Stroke
Annie Hargrave
One Liner:
HPI: 68M with h/o HTN, DM is BIBA when he was found down by his wife. She
states that she last saw him normal 1 hour ago when he was washing the dishes
after dinner. She found him on the floor, unable to move his arm or leg. He could not
speak and look confused. She called 911.
Ask for more history questions: For example -
1. Did he lose consciousness? Not sure, she did not see it
2. Did he have urinary or bowel incontinence? No
3. Did he bite his tongue? No
4. Has this happened in the past? No
5. Had he had a HA? No
6. Is he on insulin or any other hypoglycemic?
PMH: HTN, DM once told that he had a “strange heart beat”
Med: HCTZ, metformin – not compliant for the last year
All: penicillin
Sx: Recently moved and has been dealing with the death of his grandson so he has
not been to see a physician in about a year.
HRB: smokes 1ppd x20 year, 1 beer at night, little exercise
DDX: Unprovoked Fall with AMS
(1) Stroke (Hemorrhagic vs Thrombo-embolic)
(2) Seizure with Todd’s Paralysis
(3) TIA – last warning, increased risk of stroke in the next week – Use ABCD^2 score
to calculate risk
(4) Hypoglycemia
(5) Syncope
Todds Paralysis – focal area of weakness after a seizure that usually affect the
appendages, but can also cause speech deficits. Usually subsides within 48hrs for
partial focal seizure or focal that generalizes.
Hemorrhagic – HA that gradually worsens
Thromboembolic – Often sudden onset of maximum severity of symptoms +/- HA
TIA – transient blockage of an artery. By definition, neurological symptoms much
last less than 24 hours.
Exam:
Gen: lethargic, confused thin man
HEENT: normocephalic, atraumatic, tongue without lacerations, PEERL but gaze
preference towards the side of the left (location: frontal eye fields)
CV: irregularly, irregular beat, tachycardic, no mumers
, Pulm: CTAB
Abd: Non-TTP, BS present
GU/GI; no incontinence
Neuro:
Mental status: lethargic, not answering questions or following commands
Cranial Nerves: Facial nerve: Right face weakness of lower half – able to lift eye
brows (motor cortex – UMN)
Motor: Right arm weakness > right leg weakness (motor cortex)
Sensory: Right loss of temperature, light touch and proprioception (sensory cortex)
Broca’s Aphasia (posterior frontal lobe)
Extremities: Babinski sign present
Location?
Left MCA (Superficial Division) – Review
Stroke
Annie Hargrave
One Liner:
HPI: 68M with h/o HTN, DM is BIBA when he was found down by his wife. She
states that she last saw him normal 1 hour ago when he was washing the dishes
after dinner. She found him on the floor, unable to move his arm or leg. He could not
speak and look confused. She called 911.
Ask for more history questions: For example -
1. Did he lose consciousness? Not sure, she did not see it
2. Did he have urinary or bowel incontinence? No
3. Did he bite his tongue? No
4. Has this happened in the past? No
5. Had he had a HA? No
6. Is he on insulin or any other hypoglycemic?
PMH: HTN, DM once told that he had a “strange heart beat”
Med: HCTZ, metformin – not compliant for the last year
All: penicillin
Sx: Recently moved and has been dealing with the death of his grandson so he has
not been to see a physician in about a year.
HRB: smokes 1ppd x20 year, 1 beer at night, little exercise
DDX: Unprovoked Fall with AMS
(1) Stroke (Hemorrhagic vs Thrombo-embolic)
(2) Seizure with Todd’s Paralysis
(3) TIA – last warning, increased risk of stroke in the next week – Use ABCD^2 score
to calculate risk
(4) Hypoglycemia
(5) Syncope
Todds Paralysis – focal area of weakness after a seizure that usually affect the
appendages, but can also cause speech deficits. Usually subsides within 48hrs for
partial focal seizure or focal that generalizes.
Hemorrhagic – HA that gradually worsens
Thromboembolic – Often sudden onset of maximum severity of symptoms +/- HA
TIA – transient blockage of an artery. By definition, neurological symptoms much
last less than 24 hours.
Exam:
Gen: lethargic, confused thin man
HEENT: normocephalic, atraumatic, tongue without lacerations, PEERL but gaze
preference towards the side of the left (location: frontal eye fields)
CV: irregularly, irregular beat, tachycardic, no mumers
, Pulm: CTAB
Abd: Non-TTP, BS present
GU/GI; no incontinence
Neuro:
Mental status: lethargic, not answering questions or following commands
Cranial Nerves: Facial nerve: Right face weakness of lower half – able to lift eye
brows (motor cortex – UMN)
Motor: Right arm weakness > right leg weakness (motor cortex)
Sensory: Right loss of temperature, light touch and proprioception (sensory cortex)
Broca’s Aphasia (posterior frontal lobe)
Extremities: Babinski sign present
Location?
Left MCA (Superficial Division) – Review
