FULL CODE CASE
DISCUSSION:
SLURRED SPEECH
GROUP -5B
Preceptor: Dr.Christine Joy Raquid
GENERAL DATA
Name: J.G
Age: 59 years old
Sex: male
Religion: not mentioned
Address: not mentioned
Civil status: married
Occupation: not mentioned
CHIEF COMPLAINT
“SLURRED SPEECH”
HISTORY OF PRESENT ILLNESS
Few hours prior to consultation patient started experiencing slurred
speech along with right sided weakness, his wife mentioned that
patient was found lying on ground with near complete right sided face,
arm and leg weakness. Hence prompted to seek consultation.
PAST MEDICAL HISTORY:
• Patient is hypertensive,
• Patient has hyperlipidemia
• Patient had undergone appendectomy
FAMILY HISTORY : Not contributory
PERSONAL AND SOCIAL HISTORY :
• Non alcoholic
• Non allergic
• Patient was a smoker, quit smoking 5 years ago.
REVIEW OF SYSTEMS
Unable to obtain due to expressive and receptive aphasia
General: (-) fatigue, (-) Night sweats, (-) weight gain, (-) chills, (-) fever
Skin: (-) itching, (-) rashes, (-) pruritus, (-) wounds
Head: (-) palpable masses, (-) lesions, (-) headache, (-) head injury
Eye: (-) visual changes, (-) eye pain, (-) double vision, (-) visual loss
Ear: (-) ear pain, (-) hearing problem, (-) discharges, (-) deafness
Nose: (-) Runny nose, (-) sinus pain, (-) epistaxis, (-) post nasal drip
Mouth: (-) dry lips & mouth, (-) bleeding gums, (-) tonsillitis, (-) sore throat
Neck: (-) lumps, (-) swollen glands, (-) stiffness of neck, (-) limitation in motion
Pulmonary system: (-) cough, (-) sputum, (-) dyspnoea, (-) haemoptysis
Cardiovascular: (-) chest pain, (-) exercise intolerance, (-) Orthopnoea, (-) palpitations
Gastrointestinal: (-) abdominal pain, (-) difficulty swallowing, (-) nausea, (-) vomiting
Genitourinary: (-) frequency in urination, (-) dysuria, (-) flank pain, (-) no penile discharge.
Neurological: (-) confusion, (-) seizures, (-) nervousness (-) focal motor or sensory loss
Haematological: (-) anaemia, (-) bleeding disorders, (-) purpura
Musculoskeletal: (-) leg pain, (-) myalgia, (-) arthralgia, (-) swelling
Psychiatric: (-) delusions, (-) depression, (-) hallucinations, (-) anxiety
Endocrine: (-) excessive sweating, (-) heat or cold intolerance, (-) thyroid problems, (-)
diabetes
PHYSICAL EXAMINATION
• General status: slurred speech, right sided droop, GCS 13
• Vital signs:
o Heart rate: 88 bpm
o Blood pressure :175/89mmHg
o Respiratory rate :18/min
o Temperature: 37 ⁰C
o Height: 179 cm
o Weight: 83 kg
Airway: Patent without obstruction or stridor.
Breath: Bilateral, symmetric breath sounds with normal chest rise.
Circulation: 2+ peripheral pulses, normal capillary refill.
Skin: warm and dry, no rashes.
HEENT: normocephalic, atraumatic, PERRL (Pupils equal round and reactive to light), EOMI
(Extraocular movements intact), oropharynx is clear. There is right sided facial droop.
Neck: no masses, trachea midline, supple with full range of motion without C-spine
tenderness.
Cardio: irregularly irregular, no murmurs, rubs, or gallops.
Pulmonary: clear to auscultation bilaterally, no retractions, no wheezes, Ronchi, or rales.
Abdominal: soft, nontender, nondistended, normal active bowel sounds, no percussion
tenderness, rebound or guarding.
Genito urinary: normal penis and testicles, no masses, no hernias.
Back: no costovertebral angle tenderness, no tenderness to the thoracic or lumbar spine.
Musculoskeletal: no clubbing, cyanosis or edema, normal range of motion without bony point
tenderness.
Neurological: somnolent, unable to follow commands. 2/5 strength in right face and arm, 3/5
strength in the right leg with aphasia. No blink to visual threat on right.
Psychiatric: unable to cooperate.
SALIENT FEATURES
59-year-old male
Slurred speech
Right side weakness 8 in arms, legs and face
Hypertension
Hyperlipidemia
Remote appendectomy
Former smoker, quit 5 years ago
Bp: 175/90 mm Hg
Finger stick blood sugar: 122mg/ dl
Capillary PE : +2 peripheral pulse
Cardiac PE : irregularly irregular rhythm
Neurologic PE: somnolent, unable to follow commands. 2/5 strength in the right face and arm,3/5 strength
in the right leg with aphasia. No blink to visual threat on right.
ECG: Atrial fibrillation at 90 bpm
MRI: There is an acute infarct in the distribution of the left middle cerebral artery.
IMPRESSION
“ ISCHEMIC STROKE”
DIFFERENTIAL DIAGNOSIS
Diagnosis Rule in Rule out
Hemorrhagic stroke (+) slurred speech, (+)unilateral in CT and MRI shows no mass or
weakness hemorrhage,(-) headache
Subdural hemorrhage (+)slurred speech, (+) motor and no sign of trauma ,(-)headache, in
sensory deficit Ct no mass or hemorrhage
Intracerebral hemorrhage (+)right sided weakness,(+) (-)headache, in Ct no mass or
slurred speech.(+) hypertension. hemorrhage
Vertebral artery dissection (+) right sided weakness (-) hoarseness, (-)vertigo, nausea
and vomiting,(-) contralateral loss
of pain.
DIAGNOSTIC TEST
PATHOPHYSIOLOGY
NAME: J.G
ELEVATED TOTAL CHOLESTROL, ELEVATED AGE: 59 YEARS OLD
ANTIHYPERTENSIVE
LDL, LOW HDL CHOLESTROL, ELEVATED GENDER: MALE
DRUG - CANDESARTAN
TRIGLYCERIDES - HYPERTENSIVE
- HYPERLIPIDEMIA
- PREVIOUS SMOKER
IRREGULARITY – IRREGULAR HEART RATE AND
VENTRICULAR ARRYTHMIA, TACHYCARDIA RHYTHM
ANEMIC IN HEMOGLOBIN AND HEMATOCRIT THROMBOTIC EMBOLISM, OCCULSION,
TEST RESULT SYSTEMIC HYPOPERFUSION
ANTITHROMBOTIC DRUG ALTE PLASE
ACUTE OCCULSION OF AN INTRACRANIAL
ASPIRIN – ANTIPLATELET AGENT CLOPIDOGRAL VESSEL
– ANTIPLATELET AGENT
CAUSES REDUCTION IN BLOOD FLOW TO THE
BRAIN REGION
SUPPLY OF OXYGEN RESTRICTED AND
REDUCED TO BRAIN
IF THE BLOOD SUPPLY TO BRAIN IS 16-18ml/100g TISSUE PER MINUTE CAUSE INFARCTION.
<20 ml/100g TISSUE PER MINUTE CAUSE ISCHEMIC WITHOUT INFARCTION
DECREASE IN CEREBRAL BLOOD FLOW TO ZERO CAUSE DEATH
OF BRAIN TISSUE WITHIN 4 – 10 MINUTE
FAILURE OF MITOCHONDRIA TO
PRODUCE ATP
MEMBRANE ION PUMP STOP
FUNCTIONING
NEURONE DEPOLARIZE
INTRACELLULAR ca+ INCREASE
INCREASE IN EXTRACELLULAR k+
ACCUMULATION OF GLUTAMATE IN
EXTRACELLULAR SPACE
NEUROTOXICITY
DAMAGE TO NEURON
CT SCAN OF CRANIUM
HYPODENSE ISCHEMIA AT THE
RIGHT PARIETOTEMPORAL
REGION OF THE BRAIN.
CELL DEATH (APOPTOSIS)
ACUTE ISCHEMIC STROKE
CENTRAL CRANIAL NERVE VII
DEVIATION OF EYES AFFECTED IN BRAIN
LOWER FACIAL DROOP ON LEFT SIDE
RIGHT GAZE DEVIATION
ACUTE ISCHEMIC STROKE
INFARCTED CEREBRAL ARTERY CEREBRAL HEMISPHERE AFFECTED
GRAY AND WHITE MATTER AT THE SITE OF
INFARCTION ARE ABRUPTLY DESTROYED UPPER MOTOR NEURONS AFFECTED
HEMIPARESIS
AT BROCA’S AREA
LEFT CEREBRAL HEMISPHERE
BROCA’S ASPHYXIA AFFECTED
SEVERE IMPAIRMENT IN WORD
RIGHT SIDED HEMIPARESIS
FLUENCY, NAMING, REPETITION
RIGHT SIDED ARM, FACE, EXTREMITY
SPEECH DIFFICULTY WEAKNESS
PHARMACOLOGICAL
MANAGEMENT
● IV access with two peripheral IV lines (avoid arterial or central line placement)
● Review eligibility for Tissue Plasminogen Activator(tPA)
● Frequent blood pressure monitoring
● No other antithrombotic treatment for 24 hours.
Drug Drug Classification Mechanism of Dosage, Rate and Common side effects
Action Frequency
Alteplase Antithrombotic Alteplase binds to 0.9mg/kg (not to Nausea, vomiting,
enzyme fibrin in a blood exceed 90mg total bleeding.
clot and activates dose)
the clot-bound 10% of the total
plasminogen, dose given as a
causing the blood bolus (one-time
clots to break dose) over 1
down and dissolve. minute
the remaining 90%
is infused (given
over) over 60
minutes
Aspirin Anticoagulants, Aspirin is a salicylate that Aspirin 325mg Anemia,
Antiplatelets exhibits analgesic, anti- orally should begin thrombocytopenia,
and Fibrinolytics inflammatory, and within 24 to 48 vomiting, dizziness.
antipyretic activities. It is hours of an
a selective and ischemic stroke,
irreversible inhibitor of but not within 24
cyclooxygenase-1 (COX-1) hours of
enzyme resulting in direct completion of
inhibition of the alteplase therapy.
biosynthesis of
prostaglandins and
thromboxanes from
arachidonic acid.
Additionally, it also
inhibits platelet
aggregation.
NON PHARMACOLOGICAL
TREATMENT
Healthy lifestyle is fundamental for non-pharmacological stroke prevention and
includes:
Healthy diet
Regular physical activity
Low-normal body mass index
Smoking abstinence and
Moderate drinking of alcohol
SURGICAL MANAGEMENT
1. Brain Bypass Surgery:
A cerebral bypass is the brain's equivalent of a coronary bypass in the heart. The surgery
connects a blood vessel from outside the brain to a vessel inside the brain to reroute blood
flow around a damaged or blocked artery. The goal of bypass surgery is to restore blood
supply to the brain and prevent strokes.
2. Cerebral angioplasty:
Cerebral angioplasty is similar to a widely used cardiology procedure and is used to open
partially blocked vertebral and carotid arteries in the neck, as well as blood vessels within
the brain.
ALGORITHM
FINAL DIAGNOSIS
ISCHEMIC STROKE:
Ischemic stroke is characterized by the sudden loss of blood circulation to an area of
the brain, resulting in a corresponding loss of neurologic function. Acute ischemic
stroke is caused by thrombotic or embolic occlusion of a cerebral artery and is more
common than hemorrhagic stroke.
Full code case has Mr. J with history of hypertension, hyperlipidemia, Atrial fibrillation,
was smoker in past.... These factors are encouraging for ischemic stroke , besides ECG
showed Atrial fibrillation, mri showed acute infarct in LMCA, patient has slurred
speech and right sided weakness this clinical manifestations and lab results highly
suggest it to be Acute Ischemic stroke.
THANK YOU.....
