# Another stroke? 85YOM



## Melclin (Oct 25, 2012)

Well I'm on leave now so I'll be doing a bit of posting in between eating and drinking my weight in cheese and wine. 

In the same vein as my other thread, here is an everyday scenario for your consideration. 

At 0127 on a reasonably warm spring morning you are dispatched to an 85YOM (? stroke - symptoms < 6hours old). Ten minute response time on one of the first warmer nights of the spring. 

You arrive at a well kept house in a relatively expensive neighbourhood and are met by the patient's anxious looking wife and directed to the pt sitting, looking oddly regal, in the lounge room of a remarkably nice house. 

85YOM. 

*Medical Hx*
"TIAs" in the chest. On further questioning, it seems like he's talking about angina. Denies MI, received 2 stents shortly afterwards, with no CP since, regular good bills of health from cardiologist. 

One episode of self resolving paroxysmal a-fib some time ago, hypertension, hypercholesterolaemia (both well controlled per regular visits to GP).

Pt reports having had the flu 6/52 previously, resolving approx 4/52 previously, with a persistent but very mild productive cough since then (clear mucous), but denies any other ailments and appears to be in remarkable health for his age. Nil orthopnea/CP/SOB on exertion/ankle oedema. Active both physically and mentally, non smoker, approx 5 standard drinks a week, takes regular long walks, plays golf, denies stressors of any kind. Normal weight and appears at least 20 years younger than stated age. 

Meds - Aspirin, Clopidogrel, candesartan, atorvastatin. 

Allergies - Penicillin (nausea, Ds & Vs)

*Hx of current illness:*
The pt states that when raising self from couch at approx 2000, he became suddenly very cold (in a warm room) and developed a tremor for approx 4 mins. Self resolving. Witnessed by wife, who states pt was not diaphoretic, pale, speaking/acting strangely, walking abnormally or suffering any facial droop. No previous episodes like this but thought little of it and went to bed. He woke at 0100 this am, wondering whether he might have had a stroke. It was at this time he also noted a mild frontal headache which he states is quite unusual for him. His wife became very worried and called an ambulance.

*Current complaints*: His only current complaint is a mild fontal headache, v mild (1/10). Non-radiating, non pulsating, nothing exacerbates the pain. Nil posterior ache or neck ache, photophobia, pain behind eyes or while moving eyes. Hasn’t taken any pain relief. 

The pt DENIES having had then, now or at any stage this week, any: 
- Chest pain/discomfort, pallor, SOB, exertional SOB, dizziness, palpitations, diaphoresis, flushing in the face. 
- Visual disturbance/blurred vision/diplopia, abnormal thoughts.
- Nausea, vomiting, diarrhoea, reduced appetite, reduced fluid intake, oliguria/dysuria. 
- Flu like symptoms, rhinorrhea, arthralgia, myalgia, night sweats, fatigue, known exposure to sick people or suspect food, generalised weakness or being generally unwell in any way.
- A history of strokes, bleeds, aneurysms or recent head trauma.

*O/E:*
HEENT/NEURO: GCS 15. Normal flexion, extension, strength & sensation in limbs, normal elevation of shoulders, nil limb drift.  PEARL, normal visual acuity & peripheral visual fields, nil nystagmus. Nil facial droop, dysarthria, dysphagia or dysphasia. Normal gait and fine motor movement. White sclera, pink conjunctiva. Nil nuccal rigidity. Didn’t test brudsinski/kernig’s signs. Doesn’t appear drowsy. 

CVS: Appears warm, pink and perfused. BP 140/80, pulse 84 (strong and regular), warm extremities. Mild moisture noted when takes dressing gown off, but house is very hot. 

Resp: Chest clear and equal bilaterally, nil increased WOB, SpO2 98 on RA, RR 16. 

Other: 
Temp 39.0 (102.2), denies abdominal discomfort, abdomen is soft and pain free on palpation. 
Normal oral intake both food and fluid, drank approx 2 litres of water today, normal bowel motions, denies melana. Moist mucousa, nil tongue furrowing, good skin turgour, orthostatic vitals not tested. 


*Whats wrong with him, what are you going to do about and to where will you transport him (if at all). *

To make things a little clearer than the last scenario, pt has a regular GP with whom he can make an appointment later that day.  A base hospital (med reg coverage, interns in ED, consultants for most except neurology, neuro & cardio thoracic surg on call) is approx 15 mins transport.


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