Family Medicine 22: 70-year-old male with new-onset unilateral weakness

Family Medicine 22: 70-year-old male with new-onset unilateral weakness

Author: George Nixon, MD; Associate Editor: John B. Waits, MD, FAAFP; Case Editor: Lacy Smith, MD
INTRODUCTION

HISTORY

You review the patient schedule with Dr. Wilson.

It is late autumn and you are working at Dr. Wilson’s office.
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Dr. Wilson looks over his patient schedule and asks you to see Mr. Glenn Wright, a 70-year-old man who has been a patient in Dr. Wilson’s practice for six years. Today, he is listed as a “walk-in” visit.
You knock, and then enter to begin this patient encounter. It is 3:15 p.m.

HISTORY OF PRESENT ILLNESS

HISTORY

You interview Mr. Wright.

You introduce yourself and begin the interview while also reviewing the EMR which displays the following chief concern: “Fell down and couldn’t get up.” Family Medicine 22: 70-year-old male with new-onset unilateral weakness.

“I understand that you are here for evaluation after falling yesterday. Can you tell me what happened?”

“Did you lose consciousness or blackout?”

“What happened next?”

MEDICAL, FAMILY AND SOCIAL HISTORY

HISTORY

You ask,

“At what time or how long has it been since this happened, Mr. Wright?”

You are concerned Mr Wright may need urgent evaluation so you proceed rapidly with focused questions.

You learn the following: Mr. Wright has some right knee soreness, but denies weakness, headache, current vision or speech problems, chest discomfort, palpitations, shortness of breath, nausea, abdominal pain, and incontinence of urine or stool.

You scan his chart in the EMR.

Summary of most recent progress note:

Date: Four months prior.

Chief Concern: Follow-up hypertension & hyperlipidemia

Subjective: Persistent stiffness in knees, but pain relieved with acetaminophen. Urine flow improved. Denies exertional chest discomfort, decreased stamina, headaches, dizziness and weakness. Occasionally omits diuretic and statin. Family Medicine 22: 70-year-old male with new-onset unilateral weakness.

ROS: Occasional dizziness and decreased energy for 2 to 3 months. Decreased night vision. Occasional heartburn, stiff back and knees. Denies fever, syncope, headache, weight loss, abdominal discomfort or change in bowel habits or stool.

Past Medical History: Essential hypertension, osteoarthritis, peptic ulcer disease, benign prostatic hyperplasia, hyperlipidemia, cataracts, shingles. No surgery.

Family History: Type 2 diabetes mellitus, hypertension, glaucoma.

Social History: Widowed for four years, retired railroad worker. Children: two daughters out-of-state and a son who lives nearby. Smoking – 1/2 pack per day resumed four years ago after ten-year abstinence. Alcohol – single shot whiskey most nights. Hobbies – quail hunting and fishing.

Medications: Hydrochlorothiazide 25 mg daily, amlodipine 10 mg daily, doxazosin 2 mg every evening, simvastatin 20 mg every evening, over the counter ranitidine, acetaminophen.

Allergies: No known allergies.

Immunizations: H zoster, pneumococcal, Tdap, and influenza vaccines current.

Objective: Blood pressure 166/80 mmHg. No carotid bruits. Lungs: Clear. Heart: Regular rhythm. Rate 70’s beats/minute, point of maximal impulse (PMI) laterally displaced. Family Medicine 22: 70-year-old male with new-onset unilateral weakness.

Labs: Fasting lipid profile: total cholesterol 190 mg/dl, HDL 31 mg/dl, LDL 129 mg/dl, triglycerides 150 mg/dl.

Assessment: Hypertension – poorly controlled, hyperlipidemia – poorly controlled, osteoarthritis of the knees, benign prostate hyperplasia. Family Medicine 22: 70-year-old male with new-onset unilateral weakness.

Plan: Follow-up 6 to 8 weeks.

Discussed importance of medication compliance, smoking cessation, and lifestyle changes on personal health risks for stroke, heart, and kidney disease. Given DASH Diet brochure and prescription coupons.

You confirm this past medical history, family history, and social history with Mr. Wright.

Question

Given Mr. Wright’s history of dizziness, visual symptoms, left arm numbness, and imbalance,

TIA (transient ischemic attack)

is on your differential along with several cardiovascular disorders. What risk factors does Mr. Wright have for cerebrovascular and cardiovascular disease (ASCVD)?

The suggested answer is shown below.
 
Letter Count: 965/1000

SUBMIT

Answer Comment

Age over 45 years

Smoking history

Hypertension

Hyperlipidemia

TEACHING POINT

Risk Factors for Cerebrovascular Disease

The risk factors for cerebrovascular disease are very similar to those for coronary artery disease.

For more REQUIRED information on ASCVD risk factors and for lifestyle modifications for ASCVD prevention, see the Aquifer Cholesterol Guidelines module.

Due to this risk, the United States Preventive Services Task Force recommends:

ALL adults >18 yrs be screened for hypertension
Adults > 20 yrs should be screened for hyperlipidemia if at increased risk for CAD (i.e., diabetic, hypertensive, premature personal history of atherosclerosis or family history of CAD in males < 50 yrs or females < 60 yrs) All adults be asked about tobacco use, and all smokers be given tobacco cessation interventions. Clinicians should discuss aspirin chemoprevention with all men over 50 for primary prevention of myocardial infarction. Family Medicine 22: 70-year-old male with new-onset unilateral weakness. References Bibbins-Domingo K, et al. Aspirin Use for the Primary Prevention of Cardiovascular Disease and Colorectal Cancer: U.S. Preventive Services Task Force Recommendation Statement. Ann Intern Med. 2016;164(12):836-845. Easton JD, Saver JL, Albers GW, et al. Definition and evaluation of transient ischemic attack: a scientific statement for healthcare professionals from the American Heart Association/American Stroke Association Stroke Council; Council on Cardiovascular Surgery and Anesthesia; Council on Cardiovascular Radiology and Intervention; Council on Cardiovascular Nursing; and the Interdisciplinary Council on Peripheral Vascular Disease. The American Academy of Neurology affirms the value of this statement as an educational tool for neurologists. Stroke 2009;40(6):2276-2293. ORTHOSTATIC VITALS PHYSICAL EXAM You perform the TUG test on Mr. Wright. While washing your hands, you tell Mr. Wright that you will be performing a physical and neurologic exam. You begin the exam testing for orthostatic changes. Orthostatic Vital Signs Position – Supine: Heart rate: 110 beats/minutes Blood pressure: 166/82 mmHg Position – Standing: Heart rate: 120 beats/minute Blood pressure: 162/80 mmHg TEACHING POINT Orthostasis A reduction of systolic or diastolic blood pressure of at least 20 or 10 mmHg respectively, measured three minutes after a patient who has accommodated to the supine position assumes a standing or sitting position. Some experts also consider the test to be positive when the pulse rate remains increased by 20 beats per minute or more (16 beats per minute in the elderly). Family Medicine 22: 70-year-old male with new-onset unilateral weakness References Consensus statement on the definition of orthostatic hypotension, pure autonomic failure, and multiple system atrophy. Orthostatic changes. J Neurol Sci. 1996;144:218-219. TIMED UP AND GO TEST PHYSICAL EXAM You perform the TUG test on Mr. Wright. You then proceed to assess Mr. Wright’s general balance, mobility, and risk for fall by having him perform the (TUG test) “Timed Up and Go” test. You know that it is important to screen rapidly patients who present with neurologic symptoms. Clinical findings can change quickly, and the establishment of a baseline provides a comparative benchmark. TEACHING POINT Timed Up and Go Test Measures mobility and fall risk in people who are able to walk on their own. The person may wear their usual footwear and can use any assistive device they normally use. Family Medicine 22: 70-year-old male with new-onset unilateral weakness. Instructions to the patient: Sit in the chair with your back to the chair and your arms resting in your lap. Without using your arms, stand up from the chair and walk 10 ft. (3m). Turn around, walk back to the chair, and sit down again. Timing begins when the person starts to rise from the chair, and ends when he or she returns to the chair and sits down. The person should be given one practice trial and then three actual trials. The times from the three actual trials are averaged. Prediction of Mobility Average Number of Seconds for TUG Mobility Prediction <10 Freely mobile < 20 Mostly independent 20-29 Variable mobility > 30

Impaired mobility

Note: This test is more discriminative in patients who are more debilitated.

TEACHING POINT

Initial Physical Exam of Neurologic Symptoms

Exam of cranial nerve VII

Facial asymmetry is not specific for stroke as it can also be caused by Bell’s Palsy or Horner’s syndrome. Weakness or asymmetry of the muscles of facial expression (CN VII) is a common presenting sign of stroke.

Auscultation of carotids

Listen for carotid bruits as emboli from carotid arteries are associated with TIA and stroke and these emboli may result in transient monocular blindness or visual field defects.

Romberg

Ischemic blood flow in the vertebrobasilar system is associated with ataxic gait and instability of balance that may be revealed with Romberg testing.

Cardiopulmonary

The presence of murmurs or irregular rhythms on thecardiovascular exam may signal valvular disease and intra-cardiac mural thrombi as sources for cardiac emboli.

Gross visual fields

Emboli from carotid bruits are associated with TIA and stroke and these emboli may result in transient monocular blindness or visual field defects.

Proprioception

Proprioceptive and spatial deficits are present in patients who have suffered brain ischemia affecting the sensory areas.

Mental status exam & assessment of motor strength

Documentation of mental status to include the level of alertness, orientation, comprehension (both receptive and expressive) and memory are essential, as are tests of gross motor strength and coordination.

12 lead electrocardiogram

An electrocardiogram can detect abnormalities of QT interval, conduction abnormalities, and ST changes suggestive of paroxysmal arrhythmia or myocardial ischemia producing transient central nervous system hypoperfusion.

References

Podsiadlo D, Richardson S. The timed ‘Up and Go’ Test: a test of basic functional mobility for frail elderly persons. J of Am Geriatr Soc 1991;39:142-148

Discriminative ability and predictive validity of the timed up and go test in identifying older people who fall: systematic review and meta-analysis. J Am Geriatr Soc. 2013 Feb;61(2):202-8. doi: 10.1111/jgs.12106. Epub 2013 Jan 25.

COMPLETING THE PHYSICAL EXAM

PHYSICAL EXAM

You check Mr. Wright’s carotids.

You perform a complete examination and record the following in the EMR:

Vital signs:

Temperature: 37 Celcius
Heart rate: 100 beats/minute
Respiratory rate: 16 breaths/minute
Blood pressure: No orthostatic changes
Weight: 80 kgs
Height: 5′ 10″
Pain: 0

Physical exam:

General: 70-year-old well-nourished man in no distress, alert, cooperative, fully oriented

TUG test: Normal

Head/Neck: Atraumatic, symmetric facies, no carotid bruit or neck vein distension.

Eyes: Normal visual acuity, pupils equal, round, reactive to light and accommodation (PERRLA), extraocular movements intact (EOMI), no nystagmus, normal visual fields, sub-optimal fundoscopic exam secondary to cataracts, but no evidence of papilledema.

Ear/Nose/Throat: Unremarkable.

Chest: Normal respirations and lung fields.

Cardiovascular: Rate 118, irregularly irregular rhythm (not previously noted), no murmur, point of maximal impulse (PMI) 5th intercostal space laterally displaced 3cm.

Abdomen: Unremarkable.

Genitourinary: Deferred.

Musculoskeletal: Strength 5/5 and equal in right upper and bilateral lower extremities, strength 4/5 in left upper extremity, osteoarthritic knee changes.

Neurological: No dysphonia or dysphagia, gag intact. No sensory or proprioceptive deficit. No Babinski, normal Romberg. FAST test: Symmetric smile. No pronator drift. Able to repeat, ‘No ifs ands or buts’ without slurring or difficulty.

TEACHING POINT

Pronator Drift

The pronator drift is one of the most sensitive tests for upper extremity weakness.
The patient is asked to flex their arms 90 degrees at the shoulders, supinate their forearms, close their eyes, and hold the position. If a forearm pronates, then the patient is said to have pronator drift on that side.

Pronator drift

TEACHING POINT

The National Institutes of Health Stroke Scale (NIHSS)

A standardized comprehensive tool with proven utility for efficiently ensuring systematic documentation of key components of the neurologic exam in a patient with suspected stroke. Its application enables performance of a standardized exam for TIA and stroke patients which then can be subsequently used by examiners to more precisely evaluate neurologic improvement and deterioration.

Use this scale to score components of the preceding examination which have been performed and to familiarize yourself with the components which ideally should have been included.

You may also view a video on the performance of the NIHSS exam.

TEACHING POINT

Face Arm Speech (FAST) Test

Face Arm Speech (FAST) test used by ambulance paramedics and physicians for the rapid clinical assessment of patients with suspected transient ischemic or stroke symptoms.
Developed in 1998 as a stroke identification instrument, to be used outside the hospital. Studies have demonstrated variable diagnostic accuracy of stroke by paramedics and emergency medical technicians with positive predictive values between 64% and 77%.
Instructions

References

Nor AM, McAllister C, Louw SJ, et al. Agreement between ambulance paramedic – and physician-recorded neurological signs with Face Arm Speech Test (FAST) in acute stroke patients. Stroke.2004;35:1355-1359. http://stroke.ahajournals.org/cgi/reprint/35/6/1355

Josephson SA, Hills NK, Johnston SC. NIH Stroke Scale reliability in ratings from a large sample of clinicians. Cerebrovasc Dis. 2006;22:389-395.

Lyden P, Raman R, Liu L, Emr M, Warren M, Marler J. NationalInstitutes of Health Stroke Scale certification is reliable across multiple venues. Stroke. 2009;40:2507-2511

University of Nebraska Medical Center. Pronator Drift (Video). Movies from the NeuroLogic Exam and PediNeuroLogic Examwebsites are used by permission of Paul D. Larsen, M.D., University of Nebraska Medical Center and Suzanne S. Stensaas, Ph.D., University of Utah School of Medicine. Additional materials were drawn from resources provided by Alejandro Stern, Stern Foundation, Buenos Aires, Argentina; Kathleen Digre, M.D., University of Utah; and Daniel Jacobson, M.D., Marshfield Clinic, Wisconsin. The movies are licensed under a Creative Commons Attribution-NonCommerical-ShareAlike 2.5 License.

SUMMARY STATEMENT

CLINICAL REASONING

At 3:25 p.m., Dr. Wilson knocks, enters the exam room and greets Mr. Wright just as you are concluding your exam. Aware that Mr. Wright is here for an acute care visit, Dr. Wilson has come to assess whether Mr. Wright’s visit might require his immediate attention.

Question

Based on what you know about the patient so far, write a one- to three- sentence summary statement to communicate your understanding of the patient to other providers.

Guidelines for summary statements.

Your response is recorded in your student case report.
 
Letter Count: 513/1000

SUBMIT

Answer Comment

Mr. Wright is a 70-year-old man with poorly controlled hypertension and hyperlipidemia who presents after an episode of lightheadedness that resulted in a fall. There was associated left hand numbness and visual disturbance but no loss of consciousness and all symptoms resolved after 15 minutes. Physical exam is remarkable for elevated blood pressure, irregularly irregular heart rhythm, and tachycardia.

The ideal summary statement concisely highlights the most pertinent features without omitting any significant points. The summary statement above includes:

Epidemiology and risk factors: 70-year-old man with poorly controlled hypertension and hyperlipidemia.
Key clinical findings about the present illness using qualifying adjectives and transformative language:

associated left hand numbness
associated visual disturbance
symptoms resolved after 15 minutes
elevated blood pressure on exam
irregularly irregular heart rhythm
tachycardia

DIFFERENTIAL DIAGNOSIS

CLINICAL REASONING

ELECTROCARDIOGRAM

TESTING

Mr. Wright’s electrocardiograph

Question

After you have finished discussing your current differential diagnosis with Dr. Wilson, the nurse returns to the hallway and gives you Mr. Wright’s electrocardiograph. Dr. Wilson asks you, “What is your interpretation of this?” Your interpretation statement should include descriptions of rate, rhythm, axis (normal or abnormal), hypertrophy, and ST segment.

The suggested answer is shown below.
 
Letter Count: 0/1000

SUBMIT

Answer Comment

Irregularly irregular rate of 168 beats/minute. Rhythm of supraventricular origin with normal but leftward axis, left ventricular hypertrophy (LVH), Inferior and lateral ST depression. Dx: Atrial fibrillation with LVH, inferior & lateral ST depression.

TEACHING POINT

Atrial Fibrillation – Definition, Epidemiology, & Characterization

Definition

Atrial fibrillation is rapid, irregular, and chaotic atrial activity without definable p waves on electrocardiogram. Its presence should be suspected in individuals presenting with dizziness, syncope, dyspnea, or palpitations. While palpation of an irregular pulse or auscultation of an irregular heart rate may raise suspicion of atrial fibrillation, the diagnosis requires confirmation with electrocardiogram.

Epidemiology

Atrial fibrillation (AF) is the most common arrhythmia physicians face in clinical practice, accounting for about one-third of hospitalizations for arrhythmia. The prevalence of AF increases with age and the severity of congestive heart failure or valvular heart disease. Furthermore, in most cases, AF is associated with the cardiovascular diseases of hypertension, coronary artery disease, cardiomyopathy, and mitral valve disease. Pulmonary disorders of COPD, obstructive sleep apnea, and pulmonary embolism are associated and predisposing factors. Other associated conditions include surgery, excess alcohol intake, hyperthyroidism, and febrile illnesses.

Distinguishing persistent vs. paroxysmal

Atrial fibrillation less than 72 hours total duration would be classified as new onset. Chronic atrial fibrillation may be either persistent or paroxysmal. In the paroxysmal form, atrial fibrillation may recur and then revert back to normal rhythm spontaneously, with variable periods of normal sinus rhythm between episodes. The presence of normal rhythm does not rule out the existence of paroxysmal atrial fibrillation. This arrhythmia can occur episodically without clinical detection or significant symptoms for several months.

In this case example, atrial fibrillation may have contributed to the fall, and spontaneously reverted to sinus rhythm before the ambulance arrived, later recurring prior to your examination of the patient.

DEEP DIVE

References

January CT, Wann LS, Alpert JS, Calkins H, Cigarroa JE, Cleveland JC Jr, et. al. 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol. 2014;64:e1–76.

Page RL. Newly diagnosed atrial fibrillation. N Engl J Med. 2004;351:2408-2416.

Rathore S, Berger A, Weinfurt K, et al. Acute myocardial infarction complicated by atrial fibrillation in the elderly: Prevalence and outcomes. Circulation. 2000;101;969-974.

MECHANISMS OF TIAS OR POSSIBLE STROKE

TEACHING

“So, let’s see if we can fit our findings together into something that makes sense. Mr. Wright presented with numbness, vision changes, transient weakness, and incoordination that occurred yesterday but has since resolved. What are the four cardiovascular or cerebrovascular mechanisms of TIA or stroke that we have to consider in the evaluation of these symptoms?” prompts Dr. Wilson.

Question

List the four cardiovascular or cerebrovascular mechanisms of TIAs or possible stroke which should be considered in Mr. Wright.

The suggested answer is shown below.
 
Letter Count: 148/1000

SUBMIT

Answer Comment

Embolic
Thrombotic
Cardiogenic
Hemorrhagic

TEACHING POINT

Mechanisms of TIAs or Possible Stroke

Cardiovascular or Cerebrovascular Mechanisms:

1.Embolic

Most commonly from the heart or carotid artery– arrhythmias may produce emboli from mural thrombi, atrial appendages, or from diseased heart valves

2.Thrombotic

Native clot within the intracranial vasculature — 85% of strokes are caused by vascular occlusion (thrombotic)

3.Cardiogenic

Secondary to a decrease in cerebral perfusion caused by decreased cardiac output (e.g.: anginal event associated with coronary artery disease), severe hypotension, or hypoxemia related to severe anemia or poor oxygen saturation

4.Hemorrhagic

Secondary to pathologic cerebrovascular changes within the brain attributable to aging, smoking, hypertension, and hyperlipidemia.

Hematologic and Vascular Mechanisms:

Hematologic

Hyperviscosity or myleoproliferative syndromes (polycythemia, leukemias, or thrombocytosis), vascular obstruction (sickle cell anemia), severe anemia and conditions associated with hypercoagulable states (lupus anticoagulant or antiphospholipid antibody; presence of Factor V Leiden; or deficiencies of protein C, protein S, or antithrombin III).

Vascular mechanisms

Hypertension leading to thrombosis or bleeding, atherosclerotic emboli from carotid or vertebral plaques, extrinsic compression of cranial vessels (cervical osteophytes, or rotational kinking, tumor), vasospasm (migraine, cocaine) and vasculitis.

“Let’s go tell Mr. Wright what we are thinking,” urges Dr. Wilson. “And, you know… we probably need to mention to him that we’re recommending transport to the hospital…”

DISCUSSION OF DISPOSITION

CARE DISCUSSION

Dr. Wilson explains the results of the ECG.

You and Dr. Wilson return to Mr. Wright’s room. Dr. Wilson sits down and says, “Mr. Wright, I am concerned that you may have had a TIA. Also, your electrocardiogram shows atrial fibrillation, which is an irregular heart beat or rhythm. Your fall may have been caused by a brief loss of blood flow to the brain due to your irregular heart rhythm, or it may have been related to a TIA. I am therefore recommending admission to the hospital for additional diagnostic testing and monitoring.”

Mr. Wright responds:

“I feel fine, I don’t understand why I have to be admitted into the hospital?”

“How long do you figure I’ve had this irregular heart beat? You said my heart was ok at my last exam.”

Dr. Wilson asks Mr. Wright if he has any other questions to which Mr. Wright answers “No.” You then exit to make arrangements for Mr. Wright’s transfer to the hospital.

TEACHING POINT

TIA Symptoms Preceding Stroke

Individuals experiencing TIA symptoms have been shown to have an 8% to 12% chance of having a stroke within one week and an 11% to 15% chance of having a stroke within one month.

DEEP DIVE

References

AHA. American Heart Association 2005 Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care- Part 9: Adult Stroke, Circulation. 2005;112:IV-111-IV-120.

Edward C. Jauch, Jeffrey L. Saver, Harold P. Adams et.al. “Guidelines for the Early Management of Patients with Acute Ischemic Stroke.” Stroke 2013, published online January 31, 2013.

TRANSPORT TO THE EMERGENCY DEPARTMENT

MANAGEMENT

Pending hospital transfer, you help the nurse place Mr. Wright on nasal oxygen and a continuous heart monitor. Dr. Wilson observes as you place a catheter in an antecubital fossa for IV access. You are successful on your first attempt, and your technique demonstrates familiarity with the precepts of universal precautions.

Before the EMTs arrive to transport Mr. Wright to the hospital, you discuss with Dr. Wilson that you would like to follow and to observe how the emergency room physician will evaluate and manage Mr. Wright. Dr. Wilson thinks this an excellent idea, and you agree to meet at the hospital in the morning to make rounds and follow up on Mr. Wright.

When you arrive at the emergency room, the staff physician Dr. Powell has already been filled in about Mr. Wright. His initial evaluation includes: repeating vital signs, a neurologic exam using the NIH stroke scale, and exam of the carotids, lungs, and heart. His exam is unchanged from what you found at Dr. Wilson’s office

TEACHING POINT

Stroke Systematic Assessment and Outcomes

The National Institutes of Health Stroke Scale (NIHSS) is a systematic assessment tool that provides a quantitative measure of stroke-related neurologic deficit. Originally designed as a research tool to measure baseline data on patients in acute stroke clinical trials. Now, the scale is also widely used as a clinical assessment tool to evaluate acuity of stroke patients, determine appropriate treatment, and predict patient outcome.

Patients with symptoms highly suggestive of stroke are preferentially routed to a hospital that has been certified as a stroke center, as patients with symptoms of stroke who receive treatment at hospitals with this certification have been shown to have improved outcomes among patients treated for stroke.

TEACHING POINT

Universal Precautions

Universal precautions are safety procedures designed to prevent transmission of human immunodeficiency virus (HIV), hepatitis B virus (HBV), and other blood borne pathogens when providing first aid or health care. Under universal precautions, blood and certain body fluids of all patients are considered potentially infectious for HIV, HBV and other blood borne pathogens. Implementation involves the use of protective barriers such as gloves, gowns, aprons, masks, or protective eyewear, which can reduce the risk of exposure of the health care worker’s skin or mucous membranes to potentially infective materials. Proper disposal and precautions to prevent injuries caused by needles, scalpels, and other sharp instruments or devices are also a part of this medical safety practice.

DEEP DIVE

References

Brott T, Adams HP, Olinger CP, et al. Measurements of acute cerebral infarction: a clinical examination scale. Stroke. 1989;20:864-70.

CDC. Universal Precautions for Prevention of Transmission of HIV and Other Bloodborne Infections. 1987. Updated 1996.

Edward C. Jauch, Jeffrey L. Saver, Harold P. Adams et.al. “Guidelines for the Early Management of Patients with Acute Ischemic Stroke.” Stroke 2013, published online January 31, 2013.

LABORATORY EVALUATION

THERAPEUTICS

Dr. Powell discusses stroke testing with you.

Dr. Powell finishes his exam, then the two of you briefly discuss the evaluation protocol.

TEACHING POINT

Evaluation of a Patient with Suspected Ischemic Stroke

Time is crucial in evaluation of a patient with suspected ischemic stroke because if given within four-and-a-half hours, intravenous t-PA has proven benefit in salvaging hypoxic brain tissue. Intra-arterial therapy improves functional outcomes if it can be given within six hours.

Since time is so critical, there is an organized protocol for the emergency evaluation of patients with suspected stroke. The goal is to complete an evaluation and to decide treatment within 60 minutes of the patient’s arrival in the emergency department. A designated acute stroke team includes physicians, nurses, and laboratory/radiology personnel. All patients with suspected acute stroke are triaged with the same priority as patients with acute myocardial infarction or serious trauma, regardless of the severity of the deficits.

As for all critically ill patients, the initial evaluation follows the path evaluation and stabilization of the patient’s CABs (circulation, airway, breathing). This is quickly followed by a secondary assessment of neurological deficits and possible comorbidities with the National Institutes of Health Stroke Scale (NIHSS).

The overall goal is not only to identify people with possible stroke, but also to exclude stroke mimics, identify other conditions requiring immediate intervention, and determine potential causes of the stroke for early secondary prevention.

A limited number of hematologic, coagulation, and biochemistry tests are recommended during the initial emergency evaluation of a patient with suspected acute ischemic stroke.

Although it is desirable to know the results of these tests before giving recombinant tissue Plasminogen Activator (rtPA), thrombolytic therapy should not be delayed while awaiting the results unless:

there is clinical suspicion of a bleeding abnormality or thrombocytopenia
the patient has received heparin or warfarin
use of anticoagulants is not known

Question

Several tests are recommended to be performed routinely in patients with suspected ischemic stroke to identify systemic conditions that may mimic or cause stroke or that may influence therapeutic options. If you were to imagine that Mr. Wright were presenting with symptoms of an acute stroke, which studies would you order now for Mr. Wright? Select all that apply.

The best options are indicated below. Your selections are indicated by the shaded boxes.

A. Toxicology screen

B. Blood alcohol level

C. Noncontrast brain CT or brain MRI

D. Blood glucose

E. Serum electrolytes/renal function tests

F. ECG

G. Markers of cardiac ischemia

H. Complete blood count, including platelet count

I. Prothrombin time/international normalized ratio (INR)

J. Activated partial thromboplastin time

K. Oxygen saturation

L. Chest radiography

M. Lumbar puncture

SUBMIT

Answer Comment

The correct answers are C, E, F, G, H, I, J, K, L.

TEACHING POINT

Recommended Tests for the Initial Emergency Evaluation of a Patient with Suspected Acute Ischemic Stroke

The American Heart Association/American Stroke Association Stroke Council, Clinical Cardiology Council, Cardiovascular Radiology and Intervention Council, and the Atherosclerotic Peripheral Vascular Disease and Quality of Care Outcomes in Research Interdisciplinary Working Groups have all come together to create guidelines for the early management of adults with ischemic stroke. The following tests are recommended.

CT and MRI

Imaging of the brain is recommended before initiating any specific therapy to treat acute ischemic stroke. Multimodal CT and MRI may provide additional information that will improve diagnosis of ischemic stroke.

Class I, Level of Evidence A

Renal function / electrolytes

Abnormalities of renal function or electrolyte disturbances are prevalent in patients who have risk factors for stroke and should be assessed.

Class I, Level of Evidence B

Electrocardiogram (ECG)

An electrocardiogram (ECG) is recommended because of the high incidence of heart disease in patients with stroke.

General agreement supports the use of cardiac monitoring to screen for atrial fibrillation and other potentially serious cardiac arrhythmias that would necessitate emergency cardiac interventions. It is generally agreed that cardiac monitoring should be performed during the first 24 hours after onset of ischemic stroke.

Class I, Level of Evidence B

Markers for cardiac ischemia

Markers for cardiac ischemia are important for all patients with suspected ischemic stroke, as myocardial ischemia is a potential complication of acute cerebrovascular disease.

CBC and PT/PTT

Abnormalities o

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