Case 22 - 70 yo with unilateral weakness

Question 1

Atrial fibrillation presentation

Answer 1

dizziness, syncope, dyspnea or palpitations

Question 2

Afib prevalence

Answer 2

most common arrhythmia

Question 3

Afib etiology

Answer 3

fever, myo or pericarditis, volume contraction, thyrotoxicosis, endogenous catecholamines

Question 4

Afib classification

Answer 4

New onset - less than 72 hrs total duration
Chronic - persistent vs. paroxysmal
With rapid ventricular response

Question 5

Afib complications

Answer 5

hemodynamic instability, functional impairment, heart failure, ischemia

Question 6

TIA vs stroke

Answer 6

TIA - brief episode of neuro dysfxn, sx lasting less than one hour, no evidence of infarction on imaging
Stroke - focal neuro impairment of sudden onset lasting more than 24 hours

Question 7

Screening for CVA risk factors

Answer 7

all adults >18 for HTN
adults >20 for hyperlipidemia if at increased risk
ask about tobacco use, encourage cessation
start aspirin in all men >45

Question 8

Post stroke depression

Answer 8

MDD seen in 1/3 of stroke survivors, impedes rehab and is assoc with impaired outcome, SSRIs are first line therapy

Question 9

Activities of daily living (ADL)

Answer 9

bathing, dressing and undressing, eating, transferring from bed to chair and back, voluntary control of urinary and fecal discharge, using the toilet, walking

Question 10

Instrumental or community activities of daily living

Answer 10

not necessary for fundamental functioning but enable individual to live independently in community: light housework, preparing meals, taking meds, shopping for groceries, using telephone, managing money

Question 11

Physical exam for geriatrics

Answer 11

Evaluate orthostasis: 20 mm Hg drop in systolic or 10 mm Hg in diastolic
Timed up and go test - three trials - average time 30 is impaired mobility

Question 12

Exam for stroke

Answer 12

Cranial nerves, auscultation of carotids for bruits, romberg’s, cardiopulm, visual fields, proprioception, mental status, pronator drift, face arm speech test, NIH stroke scale,

Question 13

Differential diagnosis for 70 yo with unilateral weakness

Answer 13

1. Brain tumor - alterations in vision, paresthesias, behavioral or cognitive changes
2. seizure disorder - can be preceded by aura, can be followed by paralysis (Todd’s paralysis), associated with amnesia of the event
3. Stroke - sudden numbness, weakness, confusion, trouble speaking or understanding, trouble seeing, walking, severe headache
4. TIA - transient (<1hr) neuro dysfxn without evidence of infarction, by definition consciousness is not impaired, same risk factors as stroke
5. Coronary artery disease - lightheadedness, brain injury can be caused by brain hypoperfusion
6. Medication side effects
   Less likely: Hypoglycemia, temporal arteritis, hypokalemic periodic paralysis, hemiplegic migraine

Question 14

Studies for stroke

Answer 14

• CT and MRI
• blood glucose
• renal fxn, electrolyte disturbances
• 12 lead EKG (r/o afib)
• troponins, bnp
• CBC/PTT
• pulse ox
• LP if meningitis is suspected

Question 15

Afib management

Answer 15

• IV diltiazem, beta blockers or verapamil to slow heart rate
• cardioversion in patients who have af >48 hours or who are not anticoagulated

Question 16

Stroke management

Answer 16

• triage and route to stroke center
• assess neuro deficits
• evaluate for use of tpa (<3 hours)
• emergency CT scan for hemorrhage

Question 17

Secondary prevention of stroke

Answer 17

• daily aspiring, ticlopidine or clopidogrel for non cardioembolic events
• warfarin for cardioembolic events, consider carotid endarterectomy
• treat risk factors: hypercholesterolemia (LCL<70 for very high risk), hypertension, smoking, diet, alcohol, exercise