For my Internal Medicine rotation, I had the opportunity to present some cases to Andrea, a former York College graduate. Of the two cases I presented, I found the 41 year old man who had suffered a stroke the most interesting. The patient had a 10-pack-year history of smoking and HTN, and presented to the ED for confusion, disorientation, clumsiness of right hand, and bilateral leg heaviness for 5 days. His chief complaint was “I’ve been very forgetful and confused” for 5 days. His girlfriend had noted the patient had not been his “usual self” and stated she had been hospitalized for a few days over the weekend, and they had been texting during that time and the patient texted the girlfriend saying that he had seen her in the house that day. The patient did not seem to remember that his girlfriend was in the hospital. She also reported that the patient’s texts became incoherent, and the patient himself admitted to having difficulty texting the words he wanted to, and that his messages were unintelligible. He also endorsed picking up a cup and dropping it to the floor, and difficulty walking upstairs due to heaviness in both legs with weakness worse in right leg. He also mentioned he got pulled over while driving the day prior for not realizing he drove down the wrong way on a one-way street. The patient denied headaches, numbness, chest pain, changes in vision, falls, dizziness, leg pain, recent travel, long car rides, facial droop or slurred speech.
My initial differential diagnoses based on this history were TIA, ischemic stroke and intracerebral hemorrhage.
On exam, the patient had mild ptosis of the left eye, good muscle bulk and tone with strength 4/5 in the right lower extremity and 5/5 in bilateral upper extremities and left lower extremity, but no fasciculations. He also had (+) pronator drift. Otherwise, the rest of the neurological exam was unremarkable, as well as the remainder of the physical exam. The NIH stroke scale score was a total of 1 for drift of right arm.
As for as labs that were ordered, the lipid panel showed elevated cholesterol and low HDL levels. CT of the head was notable for right acute ischemic basal ganglia, corona radiate and caudate nucleus infarct. CTA of the head and neck showed moderate stenosis of right internal cerebral artery, supraclinoid, and high-grade stenosis of left cavernous internal cerebral artery.
Based on the physical exam findings, the patient’s current smoking history, and uncontrolled hypertension, and elevated cholesterol, my leading differential was ischemic stroke. Once we had the labs and imaging, my assumption was confirmed. I found this case interesting because his mental status fluctuated, and he didn’t have a lot of physical exam findings that were consistent with a stroke. The patient and his girlfriend endorsed confusion and incoherent texting but when we saw him, he was alert and oriented x 3.
After receiving feedback from my site evaluator, she had questions about why it was pertinent to state that the patient was right-handed to which I responded explaining that I was strictly on the stroke team that week so it was pertinent information that the neurological team looks for. She also mentioned that I should include details about symmetry of the lips and whether the tongue is midline in the mouth and pharynx physical exam; however, you will find that I noted that under the neurological exam.
