Case Presentation and Discussion:
This is a 67-year-old white female that presented to the ED on 12/13/2017 around 1330 with C/O Aphasia, left sided facial droop and left hemiplegia (JT daughter, personal communication, Feb, 23, 2018). Patient reports that the onset of symptoms was sudden but is unable to recall the time of occurrence (JT, personal communication Feb.23, 2018). EMTs arrived at around 1245 for pick up (JT daughter, personal communication, Feb.23, 2018). A CTA was performed revealing a right Middle cerebral Artery occlusion (medical record, Dec.13, 2017). Altepase tPA was administered at 1430 and the patient was transferred to surgery for a thrombectomy (medical record, Dec, 13, 2017). The patient showed some improvement in speech, sensitivity, and left sided motor control 48hrs after surgery (medical chart, Dec.16, 2017). JT has a history that is significant for primary HTN and estrogen replacement (JT daughter, personal communication, Feb. 23, 2018).
History and Physical Exam:
The patient’s history is significant for HTN, migraine, and long-term estrogen replacement. JT reports a “screaming headache” and an impending sense of doom just before the onset of symptoms (JT, personal communication Feb.23, 2018). The interviewees do not recall any specific vital signs, just that the patient’s BP was “really high like 200 over something” (JT daughter, personal communication, Feb. 23, 2018).
Objective symptoms reported were significant for expressive aphasia (Brocas Area), contralateral motor weakness and loss of sensation.
I would have liked to know the exact time of the onset of symptoms, the readings on a full set of vital signs, and the results of a CBC, Chem-8, PT/INR, PTT, and D-dimer.
I was lucky in that the patient kept the results of her CTA and discharge paperwork from the hospital. According to the radiologist report, the CT showed “equivocal hypodensity in the left middle cerebral artery” and the CTA showed a “left middle cerebral artery occlusion”(medical record, Dec, 13, 2017). The patient recalls having blood taken but not the specific tests run.
Standard tests used to rule out mimicry and confirm a diagnosis and cause of stroke include: CBC with diff, Blood glucose, Toxicology, Coagulopathy studies, CT, CTA, MRI, and NIHSS (Jauch Et al., 2013)
Management and Education:
The patient was treated with tPA on admission to the hospital. She is currently taking statins and antihypertensives as well as anticoagulants (JT daughter, personal communication, Feb. 23, 2018). JT also receives physical therapy and nursing care through a local home health agency. Current education for this patient adheres to AHA stroke guidelines and includes: Nutritional management, medication adherence, activity tolerance, and disease comorbidities (Kernan et al., 2014).
Risk Factors and Prevention:
The patient’s risk factors include: dislipidemia, female, sedentary lifestyle, long-term use of estrogen replacement therapy, HTN, and age. She is not obese, does not have A-fib, does not smoke or drink alcohol, and does not have a family history of CVA or clotting disorders (JT, personal communication Feb.23, 2018).
In addition to her medication regimen, JT is currently undergoing the following prevention strategies: Daily exercise along with physical therapy three time a week. Low sodium, low sugar diet “Whole 30” (JT daughter, personal communication, Feb. 23, 2018). Additionally, She has discontinued the estrogen treatments. It would appear that she is currently following the AHA recommended guidelines for stroke prevention (Meschia et al., 2014).
JT, personal communication Feb.23, 2018
JT daughter, personal communication, Feb. 23, 2018
Jauch, E. C., Saver, J. L., Adams, H. P., Bruno, A., Connors, J. (., Demaerschalk, B. M., . . . Yonas, H. (2013, March 01). Guidelines for the Early Management of Patients With Acute Ischemic Stroke. Retrieved February 25, 2018, from http://stroke.ahajournals.org/content/44/3/870
Kernan, W. N., Ovbiagele, B., Black, H. R., Bravata, D. M., Chimowitz, M. I., Ezekowitz, M. D., . . . Wilson, J. A.
(2014, July 01). Guidelines for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack. Retrieved February 25, 2018, from http://stroke.ahajournals.org/content/45/7/2160
Meschia, J. F., Bushnell, C., Boden-Albala, B., Braun, L. T., Bravata, D. M., Chaturvedi, S., . . . Wilson, J. A. (2014, January 01). Guidelines for the Primary Prevention of Stroke. Retrieved February 25, 2018, from http://stroke.ahajournals.org/content/early/2014/10/28/STR.0000000000000046
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