Week 1 - Vision and speech difficulties

Question 1

Mr. S.L. a 72-year-old Caucasian male is bought into ED by his wife at 7.30am. He had vision and speech difficulties at dinner last night - approximately 12 hours ago.

Take a history of this patient.

HPC:
• My eye went a bit funny and my words wouldn’t come out right.
• At dinner last night ~ 12 hours ago.
• Sudden loss of vision in left eye. 3 minutes later, eye was okay. No pain.
• Friend said I was talking ‘gibberish’ lasting 10 minutes then normal.
• No limb weakness, no numbness, no gait problem, no vertigo.
• H/o fall on floor 2 weeks ago, small graze on back of head - minor.
• Hypertension and high cholesterol at age 50, thinks now ok, doesn’t like to take medicine. Feels well, eating fish more.
• Osteoarthritis both knees. R was worse until total knee joint replacement (TKJR). No other problems.

Answer 1

HPC:
• Onset.
• Character of vision/speech abnormalities.
• Alleviating factors.
• Timing - experienced it before, constant or intermittent, how long does it last?
• Exacerbating factors.
• Severity.
• Associated symptoms e.g. limb weakness, numbness, gait problem, vertigo, hemiplegia (unable to move one side of body), difficulty with speech and swallowing.
• Effect on lifestyle.

• What have you noticed has been wrong?
• How quickly did it come on? How long ago?
• Has it improved or gone away now?
• Have you ever had a stroke before? How did that affect you?
• Have you had a high BP or cholesterol (risk factors)?
• Are you a diabetic (risk factor)?
• Do you smoke (risk factor)?
• Is there a history of strokes in your family?
• Have you had palpitations or been told you have AF?
• Have you been treated with blood-thinning drugs such as aspirin or warfarin?
• Drooping of face?
• Recent falls? (subdural haemorrhage - can present later in elderly post fall e.g. 2 weeks).
• Numbness or weakness?
• Unconsciousness/syncope? (stroke knocking out both reticular activating systems).
• No dribbling (Bell’s palsy, infection)?
• Dysphagia?
• Headaches/migraines/aura (epilepsy)?

PMHx:
• Past medical history of strokes/neurological disorders, hypertension, diabetes, hyperlipidaemia, AF, bacterial endocarditis, myocardial infarction (emboli), haematological disease?
• PVD, CAD?

PSHx:
• Past surgeries?

Medications:
• Any regular medications? i.e. aspirin, warfarin (cerebral haemorrhage is a side effect of anti-platelet drugs and anti-coagulants).
• Compliance?

Allergies:
• Agent, reaction, treatment?

Immunisations:
• E.g. Fluvax, Pneumococcal.

FHx:
• Family history of any strokes/neurological disorders, hypertension, diabetes, heart disease etc?

SHx:
• Background
• Occupation
• Education
• Religion
• Living Arrangements
• Smoking
• Nutrition
• Alcohol/recreational drugs
• Physical activity

Systems Review:
• General - weight change, fever, chills, night sweats?
• CVS - chest pain, palpitations, orthopnoea/PND?
• RS - dyspnoea, cough, sputum or wheeze?
• GI - vomiting, diarrhoea, indigestion, dysphagia, change in bowel habit, abdominal pain?
• UG - dysuria, polyuria, nocturia, urgency, incontinence, urine output?
• CNS - heachaches, nausea, trouble with hearing or vision?
• ENDO - heat/cold intolerance, swelling in throat/neck, polydipsia or polyphagia?
• HAEM - easy bruising, lumps in axilla, neck or groin?
• MSK - painful or stiff joints, muscle aches or rash?

Question 2

Perform a physical examination on this patient.

Answer 2

1. Introduction, explanation, consent, hands washed.
2. General inspection: level of consciousness, orientation to person, place and time, involuntary movements, facial symmetry, signs of trauma, deformity, speech.

3. Vital signs:
• BP - hypertensive.
• HR - AF.
• RR.
• Temperature.
• BSL, BMI.

4. Hands:
   • Clubbing, asterixis (CO2 retention - hepatic encephalopathy), erythema.
5. Face:
   • Eyes - fundoscopy for hypertensive retinopathy, retinal artery emboli. Hemianaestheia and homonymous hemianopia.
6. Neck:
   • Carotid bruit - stenosis of internal carotid.
   • JVP.
7. Chest:
   • Apex beat.
   • Heart sounds/murmors.

NEURO
Cranial nerves I-XII

Upper limb
1. General inspection - asymmetry, abnormal posture, muscle wasting, scars. Handedness, fasciculations, pronator drift.

2. Muscle bulk
3. Muscle tone - flexion/extension of wrist, supination/pronation at elbow, shoulder. UMN - hypertonia.
4. Muscle power - decreased strength.
   • Shoulder - abduction (C5, C6), adduction (C6, C7, C8).
   • Elbows - flexion (C5, C6), extension (C7, C8).
   • Wrist - flexion (C6, C7), extension (C7, C8).
   • Fingers - flexion (C7, C8), extension (C7, C8), abduction (C8, T1), adduction (C8, T1).
5. Reflexes - UMN - hyperreflexia.
   • Biceps (C5, C6).
   • Triceps (C7, C8).
   • Supinator/brachioradialis (C5, C6).
6. Coordination - rapid alternating movements, finger nose test, rebound.
7. Pain
8. Position sense
9. Vibration
10. Light touch

Lower limb
1. General inspection - abnormal posture, involuntary movements, muscle wasting, fasciculations, scars. Gait (tandem, toe/heel walking), Rombergs test.

2. Muscle bulk
3. Muscle tone - passively flex/extend knee, flex/extend/invert/evert ankle, hip. UMN - hypertonia.
4. Muscle power - decreased strength.
   • Hip - flexion (L2, L3), extension (L5, S1, S2), adduction (L2, L3, L4), abduction (L4, L5, S1).
   • Knee - extension (L3, L4), flexion (L5, S1).
   • Foot - dorsiflexion (L4, L5), plantar flexion (S1, S2), eversion (L5, S1), inversion (L5, S1).
5. Reflexes - UMN - hyperreflexia.
   • Knee jerk (L3, L4).
   • Ankle jerk (S1, S2).
   • Plantar reflex (L5, S1, S2).
6. Coordination - heel to shin, toe-finger test, foot-tapping test
7. Pain
8. Position sense
9. Vibration
10. Light touch

Question 3

What is your provisional diagnosis and differential diagnoses?

Answer 3

• Provisional diagnosis: TIA (ischaemia without any neuron death - necrosis).
• DDx:
- CVA (left carotid).
- Subdural haematoma.
- Head injury.
- Electrolyte disorder.
- Space occupying lesion (brain tumour)
- Amaurosis fugax (painless temporary loss of vision in one or both eyes)/dysphasia (partial impairment of the ability to communicate resulting from brain injury).
- Epilepsy.
- Drug overdose.
- Infection.
- Migraine.

Question 4

What investigations would you carry out on this patient?

Answer 4

• FBC.
• U&E’s - electrolyte disorders i.e. hyponatremia.
• Lipids.
• ESR.
• BSL.
• CT.
• MRI - diffusion-weighted MRI is most sensitive for an acute infarct but CT helps rule out primary haemorrhage.
• ECG - to look for AF.
• Carotid Doppler USS - to look for carotid artery stenosis.
• Echocardiogram - may reveal mural thrombus due to AF or a hypokinetic segment of cardiac muscle post-MI. May also show valvular lesions in infective endocarditis or rheumatic heart disease. Transoesophageal echo is more sensitive than transthoracic.
• CXR - may show enlarged left atrium.

Question 5

What treatment does this patient require?

Answer 5

• Time to intervention is crucial. Risk of stroke within 90 days of TIA is 2% in those treated within 72 hours of TIA compared to 10% in those treated by 3 weeks.
• Control cardiovascular risk factors - hypertension, hyperlipidaemia, diabetes, help to stop smoking.
• Anti-platelet drugs:
- Clopidogrel (75mg/d) - inhibits platelet aggregation by modifying platelet ADP receptors, prevents further strokes and MIs.
- Aspirin (300mg/d - decrease after 2 weeks 75mg/d). Dipyridamole should be added to aspirin where used.
• Warfarin indications - cardiac emboli (e.g. AF, mitral stenosis, recent big septal MI).
• Carotid endarterectomy - if ≥70% stenosis at the origin of the internal carotid artery and operative risk is good. Surgery should be performed within 2 weeks of first presentation.
• Cut down alcohol - 3 full strength beers 5x days a week, more on weekends.

Stroke:
• Management is aimed at minimising the volume of brain that is irreversibly damaged, preventing complications.
• Supportive care (specialised stroke unit, rehabilitation, speech therapy, etc. - depending on needs).
• Thrombolysis (tissue plasminogen activator if given within 3 hours of symptom onset only).
• Aspirin should be started immediately after an ischemic stroke.
• Management of risk factors.

Question 6

What are the DDx for unconsciousness?

Answer 6

• Head injury
- Contusion, concussion.
- Epidural haematoma.
- Subdural haematoma.
• CVA (stroke)
- Embolic/thrombotic.
- Haemorrhagic.
• Seizure, epilepsy
• Diabetic coma - HONK, DKA, hypoglycaemia.
• Trauma - internal bleeds.
• Poisoning.
• Alcohol, drugs (e.g. sedatives, opioids).
• Anaphylaxis.
• Snake bite.
• Infections, menignitis.
• Heat stroke, hysteria.

Question 7

Outline brain anatomy and functions.

Answer 7

• Motor cortex - movement.
• Frontal lobe - judgement, foresight and voluntary movements.
• Broca’s area - speech.
• Frontal lobe - smell.
• Temporal lobe - intellectual and emotional functions.
• Sensory cortex - pain, heat and other sensations.
• Parietal lobe - comprehension of language.
• Temporal lobe - hearing.
• Occipital lobe - primary visual area.
• Wernicke’s area - speech comprehension.
• Brainstem - swallowing, breathing, heartbeat, wakefulness centre and other involuntary functions.
• Cerebellum - coordination and balance.