Comprehensive Assessment and Management of a Patient Presenting with Stroke Symptoms in the Emergency Department

QUESTION

A 60-year-old female who was taken to the ED via EMS due to a sudden onset of left-sided body weakness. The last known to be normal was 2 hours ago. The patient has PMH of HTN, HLD, and MI with 2 stents (2019). You are the provider in the ED and are assigned to manage this patient.

1. Subjective:
   • What pertinent questions will you ask the patient and/or the family?
   • What are the risk factors of this patient?
   • What other questions would you ask to help you differentiate the clinical signs and symptoms that mimic stroke?
2. Objective:
   • Complete the table below to differentiate the clinical signs and symptoms of stroke depending on the affected area.

• What tests or procedures (Lab or Diagnostic) would be perform or order for this patient?
• What other diagnostic tools would be used to help you diagnose the patient?

1. Diagnosis:
   • What are the top 3 differential diagnoses to consider for this patient, and what is the rationale?
2. Plan:
   • What is the gold standard treatment for this patient? Admit vs. Discharge? Why?

ANSWER

Comprehensive Assessment and Management of a Patient Presenting with Stroke Symptoms in the Emergency Department

Introduction

This essay addresses the case of a 60-year-old female who presents to the Emergency Department (ED) with sudden onset left-sided body weakness. As the assigned provider, the focus is on conducting a thorough assessment, differentiating stroke from other conditions, ordering appropriate tests, and formulating a plan for management.

Subjective Assessment

To gather pertinent information, it is crucial to ask the patient and/or family members specific questions. These may include:
Description of the weakness: What is the severity and location of the weakness? Does it affect the face, arm, and leg on the left side?
Time of onset: When did the weakness begin? Was the patient well just before the symptoms appeared?
Other associated symptoms: Is there any difficulty speaking, understanding speech, or vision changes? Any headache, dizziness, or loss of consciousness?
Medical history: Inquire about hypertension (HTN), hyperlipidemia (HLD), previous myocardial infarction (MI), and stent placement in 2019.

Objective Assessment

Completing the table below will aid in differentiating stroke signs and symptoms based on the affected cerebral vessels:

Cerebral Vessel Involved Clinical Manifestations
Middle cerebral artery (MCA)
Anterior cerebral artery (ACA)
Posterior cerebral artery (PCA)
Vertebral and basilar arteries
Cerebral strokes
Lacunar strokes

Diagnostic Tests and Procedures

Several tests and procedures are essential in the evaluation of a patient with suspected stroke, including:
Non-contrast CT scan of the head: It helps identify the presence of hemorrhage and provides a preliminary assessment of infarction.
Magnetic resonance imaging (MRI) and angiography (MRA): These tests offer detailed imaging of the brain and blood vessels, aiding in the identification and characterization of ischemic strokes.
Laboratory tests: Complete blood count, coagulation profile, comprehensive metabolic panel, lipid profile, and cardiac markers (troponin) may be ordered to assess risk factors and rule out other potential causes of symptoms

Differential Diagnoses

The top three differential diagnoses to consider for this patient are:
Acute ischemic stroke: Given the sudden onset of focal neurological deficits, risk factors (HTN, HLD, previous MI), and the time frame of the last known normal, stroke is the primary consideration.
Transient ischemic attack (TIA): This temporary episode of neurological dysfunction may mimic stroke but resolves within 24 hours. Differentiating between stroke and TIA is essential for appropriate management.
Intracerebral hemorrhage: In cases of acute hemorrhage within the brain, similar neurological deficits may be observed. Imaging studies, such as a CT scan, can help confirm or rule out this diagnosis.

Plan

The gold standard treatment for an acute ischemic stroke is the administration of intravenous tissue plasminogen activator (tPA) within the appropriate time window. The decision to admit or discharge the patient will depend on various factors, including the time of symptom onset, severity of symptoms, and the availability of specialized stroke units for close monitoring and interventions. Admitting the patient to the hospital is often recommended to facilitate further diagnostic evaluations, initiate appropriate treatments, and provide comprehensive care.

Conclusion

In managing a patient presenting with stroke symptoms in the ED, a comprehensive assessment and differentiation of clinical manifestations are crucial. Utilizing the appropriate diagnostic tools, such as imaging studies and laboratory tests, helps in confirming the diagnosis and ruling out other potential causes. Considering the top differential diagnoses and formulating a plan that aligns with evidence-based guidelines, such as the administration of tPA within the appropriate time frame, contributes to optimal patient outcomes. Timely intervention and a multidisciplinary approach can significantly impact the patient’s prognosis and facilitate effective management of stroke.