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.

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 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

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

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 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:

1. Sit in the chair with your back to the chair and your arms resting in your lap.
2. Without using your arms, stand up from the chair and walk 10 ft. (3m).
3. 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 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

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:

1. Epidemiology and risk factors: 70-year-old man with poorly controlled hypertension and hyperlipidemia.
2. 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

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

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

Answer Comment

1. Embolic
2. Thrombotic
3. Cardiogenic
4. 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:

1. there is clinical suspicion of a bleeding abnormality or thrombocytopenia
2. the patient has received heparin or warfarin
3. 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

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 of the CBC and PT/PTT provide information that should prompt consideration of infectious, hypoxic/hypoperfusion, thrombotic and hemorrhagic etiologies.
Oxygen saturation	Stroke etiology maybe due to underlying CAD and the extent of brain injury may be lessened by maintaining normal oxygen saturation . Hypoxic patients with stroke should receive supplemental oxygen.	Class I, Level of Evidence C

Chest x-rays have not been found to significantly alter the clinical management of patients presenting with acute ischemic stroke. In patients who may have chronic lung or cardiovascular disease chest x-rays are recommended. Chest x-rays (L) would be appropriate in Mr. Wright’s case due to his hypertension, hyperlipidemia, and atrial fibrillation.

A blood glucose should be checked to rule out hypoglycemia and, if present, treated in patients with acute ischemic stroke (Class I, Level of Evidence C). The goal is to achieve normoglycemia avoiding extremes of low or elevated blood glucose levels.

In selected patients defined by their clinical history and the circumstances of their presentation alcohol and toxicology screens may be indicated.

Lumbar puncture should be performed if there is suspicion of meningitis, endocarditis, CNS vasculitis, and when the possibility or subarachnoid hemorrhage is not eliminated by a normal or negative head CT.

Other tests that may be warranted in selected patients include: hepatic function tests, pregnancy test, arterial blood gas tests (if hypoxia is suspected), and electroencephalogram (if seizures are suspected).

DEEP DIVE

References

CVA Management. Family Practice Notebook website. http://www.fpnotebook.com/Neuro/CV/CvMngmnt.htm. Updated August 6, 2016. Accessed March 9, 2017.

Jauch E, Saver J, Adams H, Brunk A, Connors JJ, et. al. Guidelines for the Early Management of Patients With Acute Ischemic Stroke. Stroke. 2013; 44(3). http://stroke.ahajournals.org/content/44/3/870. Accessed March 9, 2017.

Powers WJ, Derdeyn CP, Biller J, et. al. 2015 American Heart Association/American Stroke Association Focused Update of the 2013 Guidelines for the Early Management of Patients With Acute Ischemic Stroke Regarding Endovascular Treatment: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke. 2015 Oct;46(10):3020-35. https://www.ncbi.nlm.nih.gov/pubmed/26123479. Accessed March 9, 2017.

NEW NEUROLOGICAL FINDINGS

PHYSICAL EXAM

You discover new weakness in Mr. Wright’s left arm.

You order the labs, and Mr. Wright is taken for a CT scan.

When Mr. Wright returns from CT, you and Dr. Powell visit him together. Dr. Powell asks you to repeat the neurological exam to assess Mr. Wright’s current status.

Neurological exam: New left arm weakness has developed since his initial evaluation in the emergency room and is his muscle strength is now 2/5. Mr. Wright is oriented and denies any chest discomfort, nausea, or shortness of breath. He is slower in responding to questions.

Vital signs: Heart rate was initially in the 70s on ER arrival and has now risen to 120 to 140 beats/minute, and his respirations have increased from 18 to 26 breaths/minute.

Labs:

- cardiac biomarkers: indeterminate
- beta-natriuretic peptide (BNP): slightly elevated.

TEACHING POINT

Cardiac Biomarkers

- Troponins and other substances are released into the blood by ischemic or infarcting myocytes.
- B-type Natriuretic Peptide (BNP) is 32-amino-acid polypeptide secreted by the cardiac ventricles in response to ventricular volume expansion and pressure overload. The levels of BNP are elevated in patients with left ventricular dysfunction, and the levels correlate with both the severity of symptoms and the prognosis.

DEEP DIVE

References

Mueller C, Scholer A, Laule-Kilian K. Use of B-Type Natriuretic Peptide in the evaluation and management of acute dyspnea. New Engl J Med. 2004;350:647-654.

Reeder GS, Kennedy HL. Diagnosis of an acute myocardial infarction. Up To Date. 2002.

ATRIAL FIBRILLATION WITH RVR

TESTING

Dr. Powell points out that Mr. Wright’s atrial fibrillation is likely episodic or intermittent with rapid ventricular response. He recognizes that Mr. Wright’s heart rate needs to be slowed and decides to use intravenous diltiazem.

TEACHING POINT

AF with Rapid Ventricular Response (RVR) – Etiology, Complications, & Treatment

AF with Rapid Ventricular Response (RVR) is the presence of physiologic or non-physiologic (electrical) ventricular tachycardia in the presence of AF.

Etiology

Fever, myocarditis, pericarditis, volume contraction, thyrotoxicosis, endogenous catecholamines, and AV nodal dysfunction are causative.

Complications

In the presence of a diminished cardiac output at baseline, AF with RVR predisposes to hemodynamic instability, functional impairment, heart failure and ischemia.

Treatment

- Rate control: Controlling the heart rate with intravenous diltiazem, beta-blockers, or verapamil improves blood flow and does not delay immediate need for emergency stroke treatment.

- Rhythm control: Cardioversion either via electric shock to the heart with the patient under sedation or via medications given orally or intravenously. Both methods carry a risk of stroke which is greatest in patients who have had atrial fibrillation for more than 48 hours, or who have not been given three weeks of prior anticoagulant therapy.

DEEP DIVE

References

Vincenza S, Weiss KB, LeFevre M, etl al. Management of newly detected atrial fibrillation: A Clinical Practice Guideline from the American Academy of Family Physicians and the American College of Physicians. Ann Intern Med. 2003;139:1009-1017.

2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation. J Am Coll Cardiol. 2014;64(21).

THROMBOLYTIC THERAPY WITH RTPR

THERAPEUTICS

Dr. Walston and Dr. Powell discuss whether to initiate thrombolytic therapy.

Earlier Dr. Powell had notified Dr. Walston, the head of the stroke unit, that Mr. Wright was in the ED, and Dr. Walston has now arrived. You remain present as Dr. Powell informs Dr. Walston of Mr. Wright’s history and status. You hear Dr. Walston say that he feels Mr. Wright has indications for thrombolytic therapy. You approach Dr. Walston: “Mr. Wright appears to have had a TIA yesterday, which is clearly more than four-and-a-half hours ago. What time should we consider our starting point for counting time in the context of decisions for rtPA?”

Dr. Walston reminds you: “Although it has been more than four-and-a-half hours since his fall yesterday, Mr. Wright had no neurologic or functional impairment when he arrived to the hospital. Because his initial hospital exam was normal, the development of new and progressing weakness in his left arm means we should consider his new symptoms a distinct new episode that started with his first appearance of symptoms here in the ED. This would have been his exam prior to having his CT scan.”

Dr. Walston tells you he’s had a chance to look at the CT scan, and the scan is negative for any evidence of acute intracranial bleed, cerebral sinus thrombosis, or prior stroke. Thus, there are no contraindications to anticoagulation in Mr. Wright’s case.

TEACHING POINT

Emergency CT Scanning and Decision to Treat with rtPA

Emergency CT scanning is done to identify most cases of intracranial hemorrhage and help discriminate nonvascular causes of neurological symptoms, like a brain tumor. The CT scan can also be examined for evidence of early signs of infarction, as widespread signs of early infarction are correlated with a higher risk of hemorrhagic transformation after treatment with thrombolytic agents. But, even so, data is insufficient that any specific CT finding (with the exception of hemorrhage) should preclude treatment with rtPA within four-and-a-half hours of stroke onset.

DEEP DIVE

References

Jauch E, Saver J, Adams H, Brunk A, Connors JJ, et. al. Guidelines for the Early Management of Patients With Acute Ischemic Stroke. Stroke. 2013; 44(3). http://stroke.ahajournals.org/content/44/3/870. Accessed March 9, 2017.

STROKE NEGLECT

PHYSICAL EXAM

Mr. Wright is showing signs of confusion.

You and Tom Wright accompany Mr. Wright to the entrance of the stroke unit where he will receive his rtPA. As Mr. Wright is being taken through the entrance Tom takes his dad’s left hand and says, “Keep the faith. You know your kids will be praying for you.” Mr. Wright turns his head to his right and asks you, “Where’s my son? I thought I heard his voice.”

You explain to Mr. Wright’s son that you will head home for the night, but you will be back in the morning with Dr. Wilson to check on his father.

Question

Right-hand dominant patients who have strokes in the area of the brain that contributes to the behavior of Mr. Wright are likely to also have which of the following associated behaviors or functional impairments? Select all that apply.

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

A. Left hemiplegia
B. Impairment of spontaneous respirations
C. Receptive aphasia
D. Expressive aphasia
E. May attempt to read while holding books upside down
F. Inattention to areas of a room
G. Denial of stroke disability
H. Left facial weakness

Answer Comment

The correct answers are A, E, F, G, H.

TEACHING POINT

Symptoms of Right Parietal Infarct

Right-hand dominant patients with strokes in the area of the brain are likely also to have left hemiplegia. Patients with right middle cerebral infarcts affecting the right parietal hemisphere may have difficulties with their spatial and perceptual abilities, which causes them to misjudge distances, or they may attempt to read holding books upside down. They may ignore people or objects in their left visual field or not pay attention to that area of the room. They may also not recognize their functional impairments (denial of stroke disability). Family Medicine 22: 70-year-old male with new-onset unilateral weakness.

Stroke Symptoms of Other Regions:

- Strokes that occur in the brain stem would likely be the cause of respiratory impairment and affect vital functions of blood pressure, heartbeat and consciousness.
- Expressive and receptive aphasia and right facial weakness are classically associated with a left middle cerebral artery stroke.
- A central nerve injury such as a stroke often spares involvement of the portion of the facial nerve that controls the forehead. This is because there is bilateral central control of this portion of the facial nerve.
- A peripheral injury to the facial nerve (such as Bell’s Palsy) causes facial weakness of the forehead.
- A more extensive listing of stroke symptoms correlating with functional neuroanatomy can be found at:http://www.fpnotebook.com/neuro/CV/IschmcStrk.htm.

Mr. Wright’s ignoring of his son and his symptoms of left upper extremity weakness are clues to the anticipated location of his evolving stroke and the functional deficits that he may develop.

STROKE UNIT

CARE DISCUSSION

The following morning you arrive at the hospital and meet Dr. Wilson at the nursing station of the stroke service where Mr. Wright has been roomed. Dr. Wilson informs you that he has seen Mr. Wright and he found him alert and stable, but with clear weakness of his left upper extremity.

You and Dr. Wilson meet up with Dr. Walston, and the three of you go into the room to see Mr. Wright. Mr. Wright’s son, Tom, is also present. Family Medicine 22: 70-year-old male with new-onset unilateral weakness.

You perform an exam:

Vital signs:

- Temperature: 37 Celsius
- Heart rate: 80s beats/minute; irregular rate and rhythm on the heart monitor
- Respiratory rate: 18 breaths/minute
- Blood pressure: 158/88 mmHg

Mr. Wright is alert, oriented to person, place, time and circumstance. No cranial nerve deficit is noted. When directed to raise his arms, he raises only the right arm even though you repeat this instruction. When noxious stimulus is applied (you press the nail of your thumb onto the base of a fingernail of the left hand), he exhibits delayed withdrawal with inattention to the cause of the discomfort. Mr. Wright volitionally moves his left leg less than his right, but, with encouragement, he demonstrates normal and equal lower extremity strength.

Dr. Walston explains, “Dr. Wilson and I think that you had a stroke affecting the right side of your brain, Mr. Wright, which would have been more severe and disabling if you had not gotten the clot dissolving medication. Tomorrow you will have a repeat CT scan of your brain which will show us how much of your brain was affected by the stroke.” Family Medicine 22: 70-year-old male with new-onset unilateral weakness.

Drs. Wilson and Walston say goodbye, and leave the room. You stay an extra minute to chat with Mr. Wright and his son. As you turn to leave, Mr. Wright’s son asks if you would remain while he prays for his father.

Question

Which of the following would be an appropriate response for a clinician who is not religious? Choose the single best answer.

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

A. I would like to, but Dr. Wilson is waiting for me to join him.
B. I don’t think I should as my faith and beliefs may differ from yours.
C. I will join you.

Answer Comment

The correct answer is C.

TEACHING POINT

Overcoming Religious Discordance in the Clinical Setting

Doctors don’t need to be religious or share the beliefs of their patients to recognize the importance of spirituality in the lives of their patients. Patients and their families who find themselves during hospitalizations under a great deal of emotional stress commonly turn to their faith to provide a context for their crisis and for emotional strength. The patient and family may judge the doctor for lack of compassion if he/she refuses to accept a request to join in prayer. Perceptions of spiritual or compassionate care are often tagged to physician behaviors such as active listening, availability, and understanding. Physician presence can lead to more effective care as it provides insight into what motivates or may inspire a patient. If the provider feels conflicted about praying with patients, he or she need only stand by quietly as the patient prays in his or her own tradition.

References

Ghosh N. The Secular Physician and the Religious Patient: Overcoming Religious Discordance in the Clinical Setting. Einstein J Biol Med. 2007;23:33-36. http://www.aecom.yu.edu/uploadedFiles/EJBM/23page33-36.pdf. Accessed April 25, 2017.

Hebert RS, MD; Jenckes MW, MPH; et al. Patient Perspectives on Spirituality and the Physician Patient Relationship. Einstein J Biol Med. 2007;23:33-36. http://www.pubmedcentral.nih.gov/picrender.fcgi?artid=1495274. Accessed April 25, 2017.

SECONDARY STROKE PREVENTION

THERAPEUTICS

Two days later, you are sitting with Dr. Wilson in his office and he says, “The results of Mr. Wright’s repeat CT are back and they confirm the presence of a right parietal infarct. That’s consistent with our clinical impression based upon the presenting history, clinical exam, and his hospital course.”

Dr. Wilson tells you, “Although the CT can confirm the clinical diagnosis, it can’t distinguish whether the cause of Mr. Wright’s ischemic stroke was thrombotic or embolic. Because of the presence of atrial fibrillation, which is associated with emboli formation in the atria and atrial appendage, this case may well have been embolic.” Family Medicine 22: 70-year-old male with new-onset unilateral weakness.

TEACHING POINT

American Heart Association (AHA) / American Stroke Association (ASA) Recommendations for Stroke Prevention

Prevention of a First Stroke

There are multiple pharmacologic choices to use to prevent stroke in patient with AF. To make this decision, utilize a risk calculator like CHADS-VASc score to determine if the patient should utilize an anti-platelet versus an anticoagulant to reduce their risk.

1. Adjusted-dose warfarin (target INR, 2.0-3.0)

Recommended for all patients with nonvalvular AF deemed to be at high risk and many deemed to be at moderate risk for stroke who can receive it safely (Class I; Level of Evidence A).

2. Antiplatelet therapy with aspirin

Recommended for low-risk and some moderate-risk patients with AF on the basis of patient preference, estimated bleeding risk if anticoagulated, and access to high-quality anticoagulation monitoring (Class I; Level of Evidence A).

3. Dual-antiplatelet therapy with clopidogrel and aspirin

Offers more protection against stroke than aspirin alone but with an increased risk of major bleeding and might be reasonable f or high-risk patients with AF deemed unsuitable for anticoagulation (Class IIb; Level of Evidence B).

4. Direct oral anticoagulants (DOACs) such as dabigatran (Class I; Level of Evidence B), apixaban (Class I; Level of Evidence B), and rivaroxaban (Class IIa; Level of Evidence B) are all indicated for the prevention of first and recurrent stroke in patients with nonvalvular AF. These agents have compared favorably to warfarin in some studies, but they can be very expensive and they require careful adherence to prevent lapses in anticoagulant protection. Family Medicine 22: 70-year-old male with new-onset unilateral weakness.

Prevention of Stroke in Patients With a History of Stroke or TIA

1. For patients with ischemic stroke or TIA with paroxysmal (intermittent) or permanent AF

Anticoagulation with a vitamin K antagonist (target INR, 2.5; range, 2.0-3.0) or DOAC is recommended (Class I; Level of Evidence A).

2. For patients unable to take oral anticoagulants

Aspirin alone (Class I; Level of Evidence A) is recommended. The combination of clopidogrel plus aspirin carries a risk of bleeding similar to that of warfarin and therefore is not recommended for patients with a hemorrhagic contraindication to warfarin * (Class III; Level of Evidence B).

The selection of an antithrombotic agent should be individualized on the basis of risk factors, cost, tolerability, patient preference, potential for drug interactions, and other clinical characteristics, including time in INR therapeutic range if the patient has been taking warfarin.

Question

Which of the following are appropriate therapies for thrombotic TIA and stroke? Select all that apply.

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

A. Aspirin
B. Aspirin with dipyridamole (Aggrenox)
C. Clopidogrel (Plavix)

Answer Comment

The correct answers are A, B, C.

Aspirin alone, aspirin with dipyridamole (Aggrenox), and clopidogrel (Plavix) are all used in the treatment of both embolic and non-embolic TIA and CVA. For aspirin, a low dose of 81 mg is recommended as higher doses (eg. 325 mg) increase side effects without substantially decreasing the risk of stroke. The addition of clopidogrel to aspirin is not recommended for stroke prevention as evidence shows that it dramatically increases gastrointestinal bleeding without a large enough benefit to warrant the addition. Most providers use aspirin as the first choice for platelet inhibitors, reserving clopidogrel for patients unable to tolerate aspirin. Family Medicine 22: 70-year-old male with new-onset unilateral weakness.

References

January CT, Wann LS, Alpert JS, 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. Kernan WN, Black HR, Bravata DM, Chimowitz MI, et al. Guidelines for the prevention of stroke in patients with stroke and transient ischemic attack: A Guideline for healthcare professionals from the American Heart Association/American Stoke Association. Stroke 2014;45:2160-2236

REHABILITATION

THERAPEUTICS

You ask Dr. Wilson if Mr. Wright should be started on anticoagulation for his atrial fibrillation. Dr. Wilson responds, “That is a very good question. It is important always to weigh the benefits and risks of anticoagulation for a patient with atrial fibrillation. It is fairly clear in the case of Mr. Wright that warfarin or a DOAC would be beneficial. In other patients, however, the decision can be more difficult.” (See the CHA2DS2-VASc Score)

Dr. Wilson goes on, “Certain types of stroke are associated with an increased risk of intracranial hemorrhage at the site of the infarct with early anticoagulation. Current guidelines recommend delaying starting anticoagulation. I would recommend he start anticoagulation in two weeks.”

“Now that we’ve dealt with that, this is a good time for us to start thinking about rehabilitation therapy for Mr. Wright,” Dr. Wilson tells you.

TEACHING POINT

Common Stroke Complications

- Aspiration pneumonia
- Malnutrition/dehydration
- Pressure sores

TEACHING POINT

Stroke Rehabilitation Therapy

Rehabilitative therapy begins in the acute-care hospital after the patient’s medical condition has been stabilized, often within 24 to 48 hours after the stroke. The first steps involve promoting independent movement because many patients are paralyzed or seriously weakened. Patients are prompted to change positions frequently while lying in bed and to engage in passive or active range-of-motion exercises to strengthen their stroke-impaired limbs. Patients progress from sitting up and transferring between the bed and a chair to standing, bearing their own weight, and walking, with or without assistance.

Rehabilitation nurses and therapists help patients perform progressively more complex and demanding tasks, such as bathing, dressing, and using a toilet, and they encourage patients to begin using their stroke-impaired limbs while engaging in those tasks. Beginning to reacquire the ability to carry out these basic activities of daily living represents the first stage in a stroke survivor’s return to functional independence.

Post-stroke rehabilitation involves physicians; rehabilitation nurses; physical, occupational, recreational, speech-language, and vocational therapists; and mental health professionals. Family Medicine 22: 70-year-old male with new-onset unilateral weakness.

TEACHING POINT

CHA2DS2-VASc Score for Atrial Fibrillation Stroke Risk

The CHA2DS2-VASc score is a validated instrument that applies known cardiovascular risk factors to provide calculated guidance to help weigh the benefits and risks of anticoagulation. A new version of the CHADS2, the CHA2DS2-VASc, is currently being evaluated.

Certain types of stroke are associated with an increased risk of intracranial hemorrhage at the site of the infarct with early anticoagulation. Current guidelines recommend delaying starting anticoagulation.

DEEP DIVE

References

Adams HP Jr, del Zoppo G, Alberts MJ, et al. American Heart Association, American Stroke Association Stroke Council, Clinical Cardiology Council, Cardiovascular Radiology and Intervention Council, Atherosclerotic Peripheral Vascular Disease and Quality of Care Outcomes in Research Interdisciplinary Working Groups. Guidelines for the early management of adults with ischemic stroke: a guideline from 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: the American Academy of Neurology affirms the value of this guideline as an educational tool for neurologists. Stroke. 2007;38(5):1655-711.

National Institute of Health. NINDS. Post-Stroke Rehabilitation Fact Sheet, NIH Publication No. 08-4846 October 2008.

NIH Stroke Scale. National Institutes of Health website. https://stroke.nih.gov/resources/scale.htm. Accessed March 9, 2017.

ACTIVITIES OF DAILY LIVING

MANAGEMENT

Mr. Wright’s hospital course proceeds without complication and he is transferred from the stroke unit to Dr. Wilson. Dr. Wilson asks you to review the record and to develop a management plan for discharge and follow-up. Family Medicine 22: 70-year-old male with new-onset unilateral weakness.

When you review his record, you note that the physical and occupational therapy notes reveal that functionally Mr. Wright is independent in basic activities of daily living (BADLs) and performs very well in skills that test instrumental or community ADLs.

TEACHING POINT

Activities of Daily Living (ADLs)

Basic activities of daily living (BADLs)

- Bathing
- Dressing and undressing
- Eating
- Transferring from bed to chair, and back
- Voluntarily control urinary and fecal discharge
- Using the toilet
- Walking (not bedridden)

Instrumental activities of daily living (IADLs) are not necessary for fundamental functioning, but enable the individual to live independently within a community

- Light housework
- Preparing meals
- Taking medications
- Shopping for groceries or clothes
- Using the telephone
- Managing money

Question

You know that survivors of a transient ischemic attack (TIA) or stroke have an increased risk of another stroke, and much of the long-term treatment is aimed at secondary prevention of another stroke. You have already prescribed antithrombotic therapy. What else do you want to consider in your management and follow-up plan for Mr. Wright? Select all that apply.

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

A. Moderate-intensity statin therapy
B. Blood pressure lowering to a goal of 130/80 mmHg
C. Blood pressure lowering to a goal of 150/90 mmHg
D. Smoking cessation
E. Mediterranean diet
F. Exercise counseling
G. Stroke education

Answer Comment

The correct answers are B, D, E, F, G.

TEACHING POINT

Secondary Stroke Prevention

The disease management program called: “Preventing Recurrence of Thromboembolic Events through Coordinated Treatment” (PROTECT) implements eight secondary prevention goals at the time of discharge. Four of these goals are aimed at treatable risk factors, and four of these goals are aimed at modifiable lifestyle risk factors of recurrent thromboembolism.

You decide to model your treatment plan after this program coordinated with recommendations from the American Heart Association and American Stroke Association.

	Recommendation	Level of Evidence
Hyperlipidemia	All patients with a history of TIA or CVA should be placed on high-intensity statin such as atorvastatin 40 or 80 mg or rosuvastatin 20 mg.	Class I, Level A
Hypertension	Antihypertensive treatment is recommended for prevention of recurrent stroke and other vascular events in persons who have had an ischemic stroke and are beyond the hyperacute period. Recent guidelines suggest that setting a blood pressure goal of 130/80 mmHg is appropriate. Given his age, one should be cautious about lowering his blood pressure too aggressively, leading to orthostasis and a subsequent fall. The older JNC8 guidelines had suggested a blood pressure goal of 150/90 mmHg for adults over age 60, but more recent evidence from the SPRINT trial argues that a lower goal in high risk patients (such as Mr. Wright, who has had a stroke already) decreases cardiovascular outcomes, particularly stroke. JNC-8 guidelines also recommend utilizing an ACEi and a diuretic for recurrent stroke prevention. For more REQUIRED information about hypertension management, see the Aquifer Hypertension module.	Class I, Level A
Smoking	All ischemic stroke or TIA patients who have smoked in the past year should be strongly encouraged not to smoke.	Class I, Level C
Diet	The ACC/AHA Lifestyle Guidelines recommend all adults consume a Mediterranean diet to reduce their risk of ASCVD. Furthermore, patients with hypertension should limit sodium intake to 2,400 mg per day or less. Family Medicine 22: 70-year-old male with new-onset unilateral weakness.	Class I, Level A
Physical activity	On the basis of moderate quality evidence, all adults are encouraged to engage in moderate-to-vigorous intensity physical activity 3-4 times per week for 40 minutes per session. For those with disability after ischemic stroke, a supervised therapeutic exercise regimen is recommended.	Class IIb, Level C
Stroke education	Stroke education including knowledge of stroke warning signs and need to call 911 in the event of a cerebrovascular event as well as awareness of individual’s own risk factors.

You decide to discontinue Mr. Wright’s simvastatin and initiate atorvastatin at 40 mg po daily instead and to keep Mr. Wright’s hydrochlorothiazide and amlodipine at their current doses and to add metoprolol 25 mg po twice daily to both control his hypertension and his heart rate.

References

Eckel RH, Jakicic JM, Ard, JD, Hubbard VS, et al. 2013 AHA/ACC guideline on lifestyle management to reduce cardiovascular risk: a report of the American College of Cardiology American/Heart Association Task Force on Practice Guidelines. Circulation. 2013;00:000–000.

Ovbiagele B, Saver JL, Fredieu A, et al. PROTECT: A coordinated stroke treatment program to prevent recurrent thromboembolic events. Neuro. 2004;63:1217-1222.

Sacco RL, Adams R, Albers G, et al. Guidelines for Prevention of Stroke in Patients With Ischemic Stroke or Transient Ischemic Attack. Stroke. 2006;37:577-617.

The SPRINT Research Group. A Randomized trial of intensive versus standard blood-pressure control. NEJM. 2015;373:2103-2116.

Stone NJ, Robinson J, Lichtenstein AH, Bairey Merz CN, et al. 2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2013;00:000–000.

Whelton PK, Carey RM, Aronow WS, Casey DE Jr, Collins KJ, Dennison Himmelfarb C, et. al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Hypertension. November 13, 2017. http://www.acc.org/latest-in-cardiology/ten-points-to-remember/2017/11/09/11/41/2017-guideline-for-high-blood-pressure-in-adults. Accessed January 29, 2018. Family Medicine 22: 70-year-old male with new-onset unilateral weakness.

DISCHARGE

MANAGEMENT

Today Mr. Wright is being discharged. Dr. Wilson has asked that you take the lead in discussing issues pertaining to preventive health maintenance and discharge medications. You discuss all of the plans you have outlined with the Wrights regarding treatable risk factors (hypertension and lipid therapy) as well as modifiable lifestyle risk factors (smoking cessation, diet, exercise, stroke education). You also consider living arrangements and plans for continuing rehabilitation therapy.

Mr. Wright’s son says, “My sisters and I think it would be best if Dad stays with me and my family for a while since he has new medications. Plus, it’s more convenient while he completes his occupational and physical therapy.” Mr. Wright grumbles that he hates to be a bother, but he agrees to this arrangement. You arrange for an office follow-up appointment for Mr. Wright in one week.

TEACHING POINT

Role of Primary Care Physicians in Primary and Secondary Prevention of Cardiovascular Disease

Primary care physicians play a central role in the detection and management of cardiovascular disease risk factors, including poor nutrition, excessive alcohol intake, smoking, obesity, insufficient physical activity, hypertension, diabetes, and hyperlipidemia, in addition to secondary effects of cardiovascular disease, cancer, and stroke. Effective communication between physicians, students, patients, and families for both the primary and secondary prevention of disease requires a persistent effort. Family Medicine 22: 70-year-old male with new-onset unilateral weakness.

TEACHING POINT

Coronary Heart Disease and Stroke in African Americans

African Americans have the highest rates of coronary heart disease (CHD) of any ethnic group in America, and stroke mortality rates are strikingly high in this population group in general.

DEEP DIVE

References

Cholesterol Guidelines. Aquifer. /documents/796. Accessed March 7, 2017.

Cooper R, Cutler J, Desvigne-Nickens P, et al. Trends and disparities in coronary heart disease, stroke, and other cardiovascular diseases in the United States: findings of the national conference on cardiovascular disease prevention. Circulation. 2000;102:3137-3147.

National Institute of Health. NINDS. October 2008. Post-Stroke Rehabilitation Fact Sheet. NIH Publication No. 08-4846.

FOLLOW-UP VISIT

MANAGEMENT

Three days following hospital discharge Mr. Wright presents to Dr. Wilson’s office for follow up.

He has no concern of headache, dizziness or weakness; denies any shortness of breath, chest discomfort or palpitations; and has no bleeding or bruising; but his son relates the following concerns:

“As you know, since his discharge, Dad has been staying with me and my family. He has been progressing well with his physical therapy, and his ignoring the left side is much improved, but he’s not acting like himself. His appetite is poor, and he is easily annoyed by my sons who think he’s the world’s greatest grandpa. Yesterday, he refused to cooperate with the occupational therapist.”

On your exam you notice:

Although Mr. Wright is alert, oriented, and cooperative — the sparkly wit and spontaneity that you had observed previously is absent. His blood pressure is 136/82 mmHg, heart rate irregular at 72 beats per minute, and left arm weakness is minimal. The exam is otherwise unremarkable. a

Question

Which of the following diagnoses do you consider most likely for Mr. Wright? Choose the single best answer.

The best option is indicated below. Your selections are indicated by the shaded boxes. Family Medicine 22: 70-year-old male with new-onset unilateral weakness.

A. Progression of stroke
B. Stroke related dementia
C. Post-stroke depression
D. Major depression
E. Dysthymia
F. Personality disorder of aging
G. Side effect of medication

Answer Comment

The correct answer is C.

Mr. Wright has post-stroke depression (C). His symptoms of depressed mood, decreased appetite, and irritability have been present for one week and do not appear to be severe; his lack of a prior history of depression is also supportive.

Incorrect options:

- There is no new neurological finding suggesting progression of stroke (A) and he is improved by report of the son and your exam.
- There is no report of confusion, disorientation, memory difficulty or delusions to support the presentation of dementia (B).
- Major depression (D) is usually associated with a prior history of depression, which Mr. Wright does not have. Major depression would be considered if a patient has five or more major depressive symptoms during at least a two week period and is characterized by a level of severity that interferes with the individual’s ability to normally function or one or more activity of daily living. Note: The episode is not considered major depression if it is attributable to the direct physiological effects of a substance or to another medical condition.
- Dysthymia (E) is a state of chronic depressed mood present for two or more years on most days of the week. Family Medicine 22: 70-year-old male with new-onset unilateral weakness.
- Personality disorder of aging (F) is a fictitious diagnosis.
- Side effects of medication (G) must always be considered and there is some reported association with beta-blockers.

Major Depressive Symptoms

(1) Depressed mood most of the day, nearly every day.

(2) Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day.

(3) Significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day.

(4) Insomnia or hypersomnia nearly every day.

(5) Psychomotor agitation or retardation nearly every day.

(6) Fatigue or loss of energy nearly every day.

(7) Feelings of worthlessness or excessive or inappropriate guilt nearly every day.

(8) Diminished ability to think or concentrate, or indecisiveness, nearly every day.

(9) Recurrent thoughts of death, recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide.

TEACHING POINT

Post-Stroke Depression – Epidemiology, Definition, Cause, Complications, Management

Epidemiology

One third of stroke survivors experience post-stroke depression.

Definition

DSM 5 defines this the occurrence of a mood disorder judged to be due to the direct physiological effects of another medical condition.

Cause

The precise cause of depression following stroke is unknown and its development is thought to be due to multiple factors which include lesion location, individual adjustment to disability, and levels of family or social support.

Complications

Untreated post-stroke depression can impede rehabilitation progress and lead to impaired functional outcome, cognitive decline, and increased mortality.

Management

SSRIs are accepted first-line therapy and have been proven to improve clinical outcomes in suffers of post-stroke depression. Selection of a particular SSRI is guided by the potential for drug-drug interactions and patient tolerance.

References

Dafer RM, Rao M, Shareef A, Sharma A. Poststoke depression. (Clinical report).Top Stroke Rehabil. 2008;15:13-21.

Ansell J, Hirsh J, Hylek E, Jacobson A, Crowther M, Palareti G ANTITHROMBOTIC AND THROMBOLYTIC THERAPY, 8TH ED: ACCP GUIDELINES: Pharmacology and Management of the Vitamin K Antagonists: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest June 2008 133:160S-198S; doi:10.1378/chest.08-0670

Robinson RG, Roy J, .Lucille A, Poststroke depression: prevalence, diagnosis, treatment, and disease progression. Biol Psychiatry. 2003;54:376-87.

Whyte EM, Mulsant BH. Post stroke depression: epidemiology, pathophysiology, and biological treatment. Biol Psychiatry. 2002;52:253-264. Family Medicine 22: 70-year-old male with new-onset unilateral weakness.

POST-STROKE DEPRESSION

THERAPEUTICS

Dr. Wilson sits down and tells both of the Wrights, “Many people who survive a stroke feel fear, anxiety, frustration, anger, sadness, and a sense of grief for their physical and mental losses. These feelings are a natural response to the psychological trauma and physical disability of stroke. The physical effects of brain damage case some emotional disturbances and personality changes. Clinical depression, which is a sense of hopelessness that disrupts an individual’s ability to function, appears to be the emotional disorder most commonly experienced by stroke survivors. Post-stroke depression can be treated with antidepressant medications and psychological counseling.”

Dr. Wilson recommends a selective serotonin reuptake inhibitor (SSRI) for Mr. Wright.

Mr. Wright replies, “I’m on enough medication Dr. Wilson, I’ve had a stroke and now you want to say I’m crazy too”.

You observe as Dr. Wilson explains the chemical changes that take place in a person with depression and how in fact these changes can be precipitated by stroke. You also observe that Dr. Wilson also encourages Mr. Wright to talk about his fears associated with his recent illness.

It becomes apparent to you that Mr. Wright’s greatest fear is not the fact that he has medical conditions that potentially threaten his life. He is more concerned about his loss of independence and the burden that might place on his family. Dr. Wilson indicates that he understands that position and encourages Mr. Wright to do all he can for himself, including taking an SSRI.

Dr. Wilson also indicates to Mr. Wright that he will discuss with him the construction of a living will at a near future visit as an additional act to relieve his family of a potentially emotional burden.

At the end of the visit, both of the Wrights seem to feel better as they shake hands with you and wish you luck in the future.

References

Jorge RE, Robinson RG, Arndt S, Starkstein S. Mortality and poststroke depression: a placebo-controlled trial of antidepressants. Am J Psychiatry. 2003;160:1823-1829.

National Institute of Health. NINDS. Post-Stroke Rehabilitation Fact Sheet, NIH Publication No. 08-4846 October 2008.

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RELEASE NOTES

January 29, 2019

- Updated time reference to “yesterday” instead of “today”
- Updated to TIA from stroke
- Added new content to the Diagnostic Network area
- Added new USPSTF content
- Family Medicine 22: 70-year-old male with new-onset unilateral weakness

LEARNING OBJECTIVES

The student should be able to:

- Assess signs and symptoms of transient ischemic attack (TIA) and stroke.
- Interpret laboratory data related to patients with new onset neurological symptoms, particularly numbness or weakness in an extremity with or without accompanying speech difficulty.
- Interpret target goals for cholesterol and lipoproteins using the best available guidelines (e.g., National Cholesterol Education Program Adult Treatment Panel [NCEP ATP] III guidelines).
- Describe the appropriate therapy for acute stroke and primary and secondary prevention of stroke.
- Discuss the evidence for the role of lifestyle changes in prevention of stroke.
- Describe the importance of effective communication between physicians, students, patients, and families in the management of atherosclerotic cardiovascular disease.
- Demonstrate the ability to care for patients with coronary artery disease from diverse patient backgrounds and at different points in their illness.
- Discuss depression with a patient appropriately.
- Perform at least two commonly used tests to determine the functional ability of an elderly patient, e.g., the “Timed Up and Go” (TUG) test, and the Mini–Mental State Examination (MMSE).

QUESTION 1

SAQ

Question

You are seeing a 72-year-old woman in a family medicine office who presents reporting having had a period of facial drooping and left upper extremity weakness that lasted approximately two hours the prior day. She currently has no symptoms. She has a past medical history of hypertension and Type 2 diabetes, for which she takes losartan and metformin daily. Her family history is positive for coronary artery disease in her father. She is a daily smoker, and she does not drink alcohol. On exam, she has normal vital signs including a blood pressure of 122/74 mmHg. Her cardiac exam reveals a regular rate without murmurs. Her neurological exam is completely normal. Which of the following is the most likely pathophysiology for her presenting symptoms? Family Medicine 22: 70-year-old male with new-onset unilateral weakness

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

A.Hemorrhage of a cerebral vessel
B. Transient hypotension leading to cerebral ischemia
C. Hypertensive urgency that has since resolved
D. Acute hypoglycemia
E. Blood clot in a cerebral vessel

Answer Comment

The correct answer is E.

This patient is presenting having had a transient ischemic attack (TIA). The most common cause of a TIA is an acute clot in a cerebral vessel (most commonly embolic, but also may be due to plaque rupture in a small cerebral vessel). If the clot resolves and circulation is restored soon enough, the stereotypical cerebrovascular ischemic symptoms resolve and we deem the episode a TIA.

Cerebral hemorrhage can produce the symptoms this patient experienced. However, hemorrhage is unlikely to lead to symptoms that resolve as hers have. Once the bleeding has happened, patients typically experience the more permanent deficits of a stroke. Family Medicine 22: 70-year-old male with new-onset unilateral weakness.

Transient hypotension can cause neurologic symptoms, but these are not focal in nature (as this patient experienced) and typically involve changes in a patients overall sensorium.

A hypertensive urgency can cause generalized neurologic symptoms such as agitation or stupor, or it can cause an acute ischemic or hemorrhagic stroke with focal findings. It is a conceivable explanation for a TIA, but it is less likely in this patient with very well-controlled hypertension on only one medication.

Acute hypogycemia causes generalized neurologic findings and delirium which quickly resolve with the correction of the serum glucose. Focal neurologic findings such as this patient’s would not be caused by hypoglycemia. Furthermore, metformin used alone does not cause hypoglycemia as an adverse reaction.

QUESTION 2

SAQ

Question

A 57-year-old man presents for follow-up after suffering an ischemic stroke with residual weakness on the left. His past medical history includes type II diabetes. He smokes 1/2 pack per day of tobacco and he does not drink alcohol. He reports no medication allergies. He has at times found the costs of his medications and test strips to be a barrier to adherence. What pairing of an anti-platelet agent and its rational is the best choice for this patient? Family Medicine 22: 70-year-old male with new-onset unilateral weakness.

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

A. Aspirin 81 mg; more effective at preventing subsequent strokes than higher doses
B. Aspirin 325 mg; more effective at preventing subsequent strokes than lower doses
C. Aspirin 325 mg; fewer bleeding complications
D. Aspirin 81 mg; fewer bleeding complications
E. Clopidogrel 75 mg; optimal for patients with diabetes

Answer Comment

The correct answer is D.

Although in the past it was believed that patients on a 325 mg dose of aspirin compared to those on an 81 mg dose where conferred more protection from ischemic stroke, studies now show that increasing the dose of aspirin, while increasing the risk of hemorrhage, does not confer more benefit than the 81 mg dose. For that reason, the 81 mg dose of aspirin, is sufficient to help prevent a stroke in a patient with a TIA or other risk factors for stroke. Clopidogrel is an option for patients who have experienced stroke or TIA. It is considerably more expensive than aspirin, and thus is likely to be a barrier for this patient. Clopidogrel has not been found to be clinically superior to aspirin in general patients or those with diabetes.

QUESTION 3

SAQ

Question

You are seeing a 68-year-old woman who has presented to the emergency department with left sided facial droop, aphasia, and left sided weakness in her arm and leg. These symptoms began while she was having lunch two hours earlier. On exam, she is hypertensive and afebrile. Her neurologic exam reveals left-sided hemiparesis with expressive aphasia and left-sided hyperreflexia. When evaluating a person with a possible stroke, when might it be acceptable to administer t-PA? Family Medicine 22: 70-year-old male with new-onset unilateral weakness.

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

A. If onset of neurologic symptoms was < 8 hrs prior to presentation
B. If emergent CT head shows a hemorrhagic stroke
C. If onset of neurologic symptoms was < 4.5 hours prior to presentation
D. If emergent CT head shows multilobar infarction
E. If the patient awoke from an 8-hour sleep with stroke symptoms of uncertain duration

Answer Comment

The correct answer is C.

When assessing a patient who presents acutely with symptoms suggestive of a stroke, one possible treatment option is using recombinant tissue plasminogen activator. When used in the appropriate patient, this medication can help minimize the damage done related to suffering an acute ischemic injury to the brain. However, it is only acceptable to administer t-PA in select situations. These include when onset of neurologic symptoms has been within 4.5 hours of the onset of symptoms, emergent CT head does not show an intracranial bleed, an early acute infarct, or a brain mass. Patients with an unknown duration of stroke symptoms due to sleep should not be given t-PA.

QUESTION 4

SAQ

Question

Which of the following therapies are recommended as first-line therapy for secondary prevention of noncardioembolic TIA or noncardioembolic stroke? Family Medicine 22: 70-year-old male with new-onset unilateral weakness.

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

A. Aspirin
B. Warfarin (Coumadin)
C. Pravastatin (Pravachol)
D. Recombinant tissue plasminogen activator (t-PA)
E. Ticlopidine (Ticlid)

Answer Comment

The correct answer is A.

For noncardioembolic (or atherothrombotic, lacunar) strokes, possible first-line therapies for secondary prevention include aspirin, aspirin in combination with extended-release dipyridamole (aggrenox), and clopidogrel (Plavix).

For cardioembolic strokes, aspirin may potentially be desirable in patients with a contraindication for anticoagulation, but most people will need to be on coumadin for secondary prevention of stroke.

High-intensity statins are recommended to help treat high cholesterol in patients who have had a stroke or have risk factors for stroke. Pravastatin is a low-intensity statin, which would not be recommended in a patient with prior atherosclerotic disease such as this.

T-PA is used in the acute management of a stroke and not as secondary prevention of noncardioembolic stroke.

Ticlopidine is an antiplatelet agent that is not as effective as aspirin or clopidogrel. It is, in fact, no longer available in the U.S.

QUESTION 5

SAQ

Question

A 71-year-old woman presents to the emergency department with acute headache and numbness of the left arm for the past six hours. Past history includes hypertension and diabetes. She takes amlodipine, chlorthalidone, metformin, and rosuvastatin, but ran out of all her medications recently. Her vitals are:

- Heart rate: 80 beats/minute
- Blood pressure: 205/110 mmHg
- Respirations: 16 per minute
- Body Mass Index: 30 kg/m2

An EKG reveals normal sinus rhythm with a rate of 82 and no ischemic changes. Which of the following is the most likely diagnosis

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

A. Transient ischemic attack
B. Hypertensive emergency
C. Embolic stroke
D. Brain tumor
E. Hypoglycemia

Answer Comment

The correct answer is B.

This patient is presenting with an acute hypertensive emergency. While there is no exact threshold at which hypertensive emergency is universally defined, typically the patient has to experience severely elevated blood pressures (eg. >185/110 mmHg) and an acute elevation above the patient’s baseline. Both features are true in this case. Additionally the patient must be experiencing acute end-organ damage such as neurologic symptoms, cardiac injury or acute kidney injury. A TIA is possible in this patient, though the context of her running out of her medications and experiencing headache makes hypertensive emergency more likely. An embolic stroke is not as likely a diagnosis given that she is not in atrial fibrillation. It is still a possibility however, as the patient could have paroxysmal atrial fibrillation and only be in sinus rhythm at the time of presentation. Given her markedly elevated blood pressure, a hypertensive emergency is a more likely explanation for her current presentation. Hypoglycemia is unlikely in a diabetic who has run out of her medications. A brain tumor is a possible but not a likely explanation in this patient. Family Medicine 22: 70-year-old male with new-onset unilateral weakness.