# Dispatched for 66 y/o male stroke symptoms



## tacitblue (Jun 29, 2013)

Call: 0930 to private residence. Well kept in middle class neighborhood.

Patient is a 66 year old male who woke up this morning and felt a bit off, and when he started to eat breakfast his wife noticed left sided facial droop and slurred speech. They called his primary care physician who instructed them to call 911; you have arrived 45 minutes after symptom onset. 

Presentation: patient is seated in chair with normal posture, and appears to be anxious but in no general distress. The left side of his face is noticeably immobile. He is alert and oriented to person, place, and time. 

History: DM II, HTN, previous TIA with no residual deficit
Medications: Metformin, atenolol, ASA, fish oil
No allergies, he does smoke a pack a day and has done so for 13 years

Initial vital signs include a regular pulse of 96, BP 146/88, resp rate 18.
You are on a standard ALS unit with any piece of equipment normally found on one. Care to investigate further and come up with a diagnosis and localize the lesion?


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## JPINFV (Jun 29, 2013)

Well, even though none of his medications can cause hypoglycemia, let's get a BGL just for giggles. Then let's do a neuro exam. Cranial nerves, sensation in UE and LE, DTRs, and motor strength please.


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## tacitblue (Jun 29, 2013)

JPINFV said:


> Well, even though none of his medications can cause hypoglycemia, let's get a BGL just for giggles. Then let's do a neuro exam. Cranial nerves, sensation in UE and LE, DTRs, and motor strength please.



Sure. The glucose is measured at 110. Neuro exam

CN 1 Smell intact during breakfast
CN 2Vision is grossly intact in both eyes, but pt complains left eye is somewhat blurry. 
CN 3, 4, 6 EOM intact, pupils are equal and responsive to light.
CN 5 Sensation is present in all branches of the trigenimal nerve although there is some paraesthesia on the left cheek.
CN 7 When the patient smiles for you, the left side is noted to respond poorly. Likewise, the left eye is easily opened by you when pt is asked to hold it shut. He cannot wrinkle the left side of his forehead
CN 8 Grossly intact bilaterally 
CN 9, 10, 11, 12 Pt sticks out his tongue, gag reflex present, uvula midline, shrugs shoulders and can turn head. Of note, he clames breakfast tasted like a roll of pennies.

Speech is slurred slightly but content is organized and clear.
Neuro exam of extremities is normal and non-focal 
DTRs are present and not hyperactive


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## tacitblue (Jun 29, 2013)

Of note, there is a local hospital with ED 10 minutes away and a hospital in a nearby city that receives stroke patients that is 40 minutes away.


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## Aidey (Jun 30, 2013)

Take him to the local hospital for his Bell's Palsy.


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## chaz90 (Jun 30, 2013)

Not to jump to a conclusion too early, but I'm going with Bell's Palsy. Have him raise his eyebrows, and I bet he'll be successful with his upper motor nerve intact controlling the forehead. His vision is blurry from his left eye since he hasn't been blinking due to lower motor nerve paralysis. Metallic taste on one side of the mouth is common with this as well. Check out extremity deficits of course during your assessment and keep looking for other causes, but all signs are pointing the same place on this one. I'd consult with the doc, but the local hospital 10 minutes out would be just fine for this transport. Hospital treatment will be supportive with a good prognosis for recovery.

Edit
I again look like a moron posting the same thing as someone else before their post shows up. One day I'll learn not to type as much...


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## Handsome Robb (Jun 30, 2013)

I agree with Bell's but what capabilities does the local ER have? If they don't have CT you need to go to the other hospital. 

Walks like a duck, quacks like a duck, it's probably a duck but he does have major risk factors for CVA so he needs to go somewhere that can rule it out. If that means the city hospital then lets get boogying cause we got a long drive.


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## Mariemt (Jun 30, 2013)

Sounds like Bells Palsy , I would go to local er,  unless they didn't have a CT. Then ask Medical direction if they want is to head to one that does. If I was wrong on the Bells, he is well into his 3 hour window.


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## tacitblue (Jun 30, 2013)

The local hospital is basic and does have CT. Are we of a consensus that this is a facial nerve palsy? How would your local systems react to you skipping the stroke protocol/activation based on your exam findings?


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## tacitblue (Jun 30, 2013)

Robb said:


> Walks like a duck, quacks like a duck, it's probably a duck but he does have major risk factors for CVA so he needs to go somewhere that can rule it out. If that means the city hospital then lets get boogying cause we got a long drive.



And that is what makes this an interesting case. Bell's palsy frequently occurs in older folks with risk factors for CVA which can complicate the diagnosis.


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## Mariemt (Jun 30, 2013)

tacitblue said:


> The local hospital is basic and does have CT. Are we of a consensus that this is a facial nerve palsy? How would your local systems react to you skipping the stroke protocol/activation based on your exam findings?


Our protocols wouldn't change at all. We would go through the motions. A detailed history, a bgl. And if there is a ct in our local hospital, that's where we go.


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## 13PappalR (Jul 8, 2013)

Although it may very well be Bell's Palsy, assume it is a stroke and per protocol take him either to a stroke center or closer hospital with a CT.


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## tchristifulli (Jul 9, 2013)

We report our findings and transport to a stroke center. If it is Bells.. Big deal. If it's a stroke atleast we have transported to a stroke center and treatment is not delayed. What designates a stroke center is having a staffed neurologist that can either respond or is in house within a certain time limit. Sounds like this guy needs a neuro eval regardless.


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## jefftherealmccoy (Jul 10, 2013)

If we took this guy to a non-stroke center, we would get reamed.  Hard.  Even if it was palsy.


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