Family Medicine 22: 70-year-old male with new-onset unilateral
weakness
User: Pamela Fay
Email:
Date: June 20, 2019 8:16PM
Learning Objectives
The student should be able to:
Assess signs and symptoms of transient ischemic attack (TIA) and stroke.
Interpret laboratory data related to patients with new onset neurological symptoms, particularly numbness or weakness in an extremity with or
without accompanying speech difficulty.
Interpret target goals for cholesterol and lipoproteins using the best available guidelines (e.g., National Cholesterol Education Program Adult
Treatment Panel [NCEP ATP] III guidelines).
Describe the appropriate therapy for acute stroke and primary and secondary prevention of stroke.
Discuss the evidence for the role of lifestyle changes in prevention of stroke.
Describe the importance of effective communication between physicians, students, patients, and families in the management of atherosclerotic
cardiovascular disease.
Demonstrate the ability to care for patients with coronary artery disease from diverse patient backgrounds and at different points in their illness.
Discuss depression with a patient appropriately.
Perform at least two commonly used tests to determine the functional ability of an elderly patient, e.g., the "Timed Up and Go" (TUG) test, and the
Mini–Mental State Examination (MMSE).
Knowledge
Risk Factors for Cerebrovascular Disease
The risk factors for cerebrovascular disease are very similar to those for coronary artery disease.
For more REQUIRED information on ASCVD risk factors and for lifestyle modifications for ASCVD prevention, see the Aquifer Cholesterol Guidelines
module.
Due to this risk, the United States Preventive Services Task Force recommends:
ALL adults >18 yrs be screened for hypertension
Adults > 20 yrs should be screened for hyperlipidemia if at increased risk for CAD (i.e., diabetic, hypertensive, premature personal history of
atherosclerosis or family history of CAD in males < 50 yrs or females < 60 yrs)
All adults be asked about tobacco use, and all smokers be given tobacco cessation interventions.
Clinicians should discuss aspirin chemoprevention with all men over 50 for primary prevention of myocardial infarction.
Orthostasis
A reduction of systolic or diastolic blood pressure of at least 20 or 10 mmHg respectively, measured three minutes after a patient who has
accommodated to the supine position assumes a standing or sitting position.
Some experts also consider the test to be positive when the pulse rate remains increased by 20 beats per minute or more (16 beats per minute in the
elderly).
Atrial Fibrillation - Definition, Epidemiology, & Characterization
Definition
Atrial fibrillation is rapid, irregular, and chaotic atrial activity without definable p waves on electrocardiogram. Its presence should be suspected in
individuals presenting with dizziness, syncope, dyspnea, or palpitations. While palpation of an irregular pulse or auscultation of an irregular heart rate
may raise suspicion of atrial fibrillation, the diagnosis requires confirmation with electrocardiogram.
Epidemiology
Atrial fibrillation (AF) is the most common arrhythmia physicians face in clinical practice, accounting for about one-third of hospitalizations for
arrhythmia. The prevalence of AF increases with age and the severity of congestive heart failure or valvular heart disease. Furthermore, in most
cases, AF is associated with the cardiovascular diseases of hypertension, coronary artery disease, cardiomyopathy, and mitral valve disease.
Pulmonary disorders of COPD, obstructive sleep apnea, and pulmonary embolism are associated and predisposing factors. Other associated
conditions include surgery, excess alcohol intake, hyperthyroidism, and febrile illnesses.
Distinguishing persistent vs. paroxysmal
© 2019 Aquifer 1/11
, Atrial fibrillation less than 72 hours total duration would be classified as new onset. Chronic atrial fibrillation may be either persistent or paroxysmal. In
the paroxysmal form, atrial fibrillation may recur and then revert back to normal rhythm spontaneously, with variable periods of normal sinus rhythm
between episodes. The presence of normal rhythm does not rule out the existence of paroxysmal atrial fibrillation. This arrhythmia can occur
episodically without clinical detection or significant symptoms for several months.
Mechanisms of TIAs or Possible Stroke
Cardiovascular or Cerebrovascular Mechanisms:
Most commonly from the heart or carotid artery-- arrhythmias may produce emboli from mural thrombi, atrial appendages, or from
1.Embolic
diseased heart valves
2.Thrombotic Native clot within the intracranial vasculature -- 85% of strokes are caused by vascular occlusion (thrombotic)
Secondary to a decrease in cerebral perfusion caused by decreased cardiac output (e.g.: anginal event associated with coronary
3.Cardiogenic
artery disease), severe hypotension, or hypoxemia related to severe anemia or poor oxygen saturation
4.Hemorrhagic Secondary to pathologic cerebrovascular changes within the brain attributable to aging, smoking, hypertension, and hyperlipidemia.
Hematologic and Vascular Mechanisms:
Hyperviscosity or myleoproliferative syndromes (polycythemia, leukemias, or thrombocytosis), vascular obstruction (sickle cell anemia),
Hematologic severe anemia and conditions associated with hypercoagulable states (lupus anticoagulant or antiphospholipid antibody; presence of
Factor V Leiden; or deficiencies of protein C, protein S, or antithrombin III).
Vascular Hypertension leading to thrombosis or bleeding, atherosclerotic emboli from carotid or vertebral plaques, extrinsic compression of
mechanisms cranial vessels (cervical osteophytes, or rotational kinking, tumor), vasospasm (migraine, cocaine) and vasculitis.
TIA Symptoms Preceding Stroke
Individuals experiencing TIA symptoms have been shown to have an 8% to 12% chance of having a stroke within one week and an 11% to 15%
chance of having a stroke within one month.
Stroke Systematic Assessment and Outcomes
The National Institutes of Health Stroke Scale (NIHSS) is a systematic assessment tool that provides a quantitative measure of stroke-related
neurologic deficit. Originally designed as a research tool to measure baseline data on patients in acute stroke clinical trials. Now, the scale is also
widely used as a clinical assessment tool to evaluate acuity of stroke patients, determine appropriate treatment, and predict patient outcome.
Patients with symptoms highly suggestive of stroke are preferentially routed to a hospital that has been certified as a stroke center, as patients with
symptoms of stroke who receive treatment at hospitals with this certification have been shown to have improved outcomes among patients treated for
stroke.
Universal Precautions
Universal precautions are safety procedures designed to prevent transmission of human immunodeficiency virus (HIV), hepatitis B virus (HBV), and
other blood borne pathogens when providing first aid or health care. Under universal precautions, blood and certain body fluids of all patients are
considered potentially infectious for HIV, HBV and other blood borne pathogens. Implementation involves the use of protective barriers such as
gloves, gowns, aprons, masks, or protective eyewear, which can reduce the risk of exposure of the health care worker's skin or mucous membranes
to potentially infective materials. Proper disposal and precautions to prevent injuries caused by needles, scalpels, and other sharp instruments or
devices are also a part of this medical safety practice.
Evaluation of a Patient with Suspected Ischemic Stroke
Time is crucial in evaluation of a patient with suspected ischemic stroke because if given within four-and-a-half hours, intravenous t-PA has proven
benefit in salvaging hypoxic brain tissue. Intra-arterial therapy improves functional outcomes if it can be given within six hours.
Since time is so critical, there is an organized protocol for the emergency evaluation of patients with suspected stroke. The goal is to complete an
evaluation and to decide treatment within 60 minutes of the patient's arrival in the emergency department. A designated acute stroke team includes
physicians, nurses, and laboratory/radiology personnel. All patients with suspected acute stroke are triaged with the same priority as patients with
acute myocardial infarction or serious trauma, regardless of the severity of the deficits.
As for all critically ill patients, the initial evaluation follows the path evaluation and stabilization of the patient's CABs (circulation, airway, breathing).
This is quickly followed by a secondary assessment of neurological deficits and possible comorbidities with the National Institutes of Health Stroke
Scale (NIHSS).
The overall goal is not only to identify people with possible stroke, but also to exclude stroke mimics, identify other conditions requiring immediate
© 2019 Aquifer 2/11
weakness
User: Pamela Fay
Email:
Date: June 20, 2019 8:16PM
Learning Objectives
The student should be able to:
Assess signs and symptoms of transient ischemic attack (TIA) and stroke.
Interpret laboratory data related to patients with new onset neurological symptoms, particularly numbness or weakness in an extremity with or
without accompanying speech difficulty.
Interpret target goals for cholesterol and lipoproteins using the best available guidelines (e.g., National Cholesterol Education Program Adult
Treatment Panel [NCEP ATP] III guidelines).
Describe the appropriate therapy for acute stroke and primary and secondary prevention of stroke.
Discuss the evidence for the role of lifestyle changes in prevention of stroke.
Describe the importance of effective communication between physicians, students, patients, and families in the management of atherosclerotic
cardiovascular disease.
Demonstrate the ability to care for patients with coronary artery disease from diverse patient backgrounds and at different points in their illness.
Discuss depression with a patient appropriately.
Perform at least two commonly used tests to determine the functional ability of an elderly patient, e.g., the "Timed Up and Go" (TUG) test, and the
Mini–Mental State Examination (MMSE).
Knowledge
Risk Factors for Cerebrovascular Disease
The risk factors for cerebrovascular disease are very similar to those for coronary artery disease.
For more REQUIRED information on ASCVD risk factors and for lifestyle modifications for ASCVD prevention, see the Aquifer Cholesterol Guidelines
module.
Due to this risk, the United States Preventive Services Task Force recommends:
ALL adults >18 yrs be screened for hypertension
Adults > 20 yrs should be screened for hyperlipidemia if at increased risk for CAD (i.e., diabetic, hypertensive, premature personal history of
atherosclerosis or family history of CAD in males < 50 yrs or females < 60 yrs)
All adults be asked about tobacco use, and all smokers be given tobacco cessation interventions.
Clinicians should discuss aspirin chemoprevention with all men over 50 for primary prevention of myocardial infarction.
Orthostasis
A reduction of systolic or diastolic blood pressure of at least 20 or 10 mmHg respectively, measured three minutes after a patient who has
accommodated to the supine position assumes a standing or sitting position.
Some experts also consider the test to be positive when the pulse rate remains increased by 20 beats per minute or more (16 beats per minute in the
elderly).
Atrial Fibrillation - Definition, Epidemiology, & Characterization
Definition
Atrial fibrillation is rapid, irregular, and chaotic atrial activity without definable p waves on electrocardiogram. Its presence should be suspected in
individuals presenting with dizziness, syncope, dyspnea, or palpitations. While palpation of an irregular pulse or auscultation of an irregular heart rate
may raise suspicion of atrial fibrillation, the diagnosis requires confirmation with electrocardiogram.
Epidemiology
Atrial fibrillation (AF) is the most common arrhythmia physicians face in clinical practice, accounting for about one-third of hospitalizations for
arrhythmia. The prevalence of AF increases with age and the severity of congestive heart failure or valvular heart disease. Furthermore, in most
cases, AF is associated with the cardiovascular diseases of hypertension, coronary artery disease, cardiomyopathy, and mitral valve disease.
Pulmonary disorders of COPD, obstructive sleep apnea, and pulmonary embolism are associated and predisposing factors. Other associated
conditions include surgery, excess alcohol intake, hyperthyroidism, and febrile illnesses.
Distinguishing persistent vs. paroxysmal
© 2019 Aquifer 1/11
, Atrial fibrillation less than 72 hours total duration would be classified as new onset. Chronic atrial fibrillation may be either persistent or paroxysmal. In
the paroxysmal form, atrial fibrillation may recur and then revert back to normal rhythm spontaneously, with variable periods of normal sinus rhythm
between episodes. The presence of normal rhythm does not rule out the existence of paroxysmal atrial fibrillation. This arrhythmia can occur
episodically without clinical detection or significant symptoms for several months.
Mechanisms of TIAs or Possible Stroke
Cardiovascular or Cerebrovascular Mechanisms:
Most commonly from the heart or carotid artery-- arrhythmias may produce emboli from mural thrombi, atrial appendages, or from
1.Embolic
diseased heart valves
2.Thrombotic Native clot within the intracranial vasculature -- 85% of strokes are caused by vascular occlusion (thrombotic)
Secondary to a decrease in cerebral perfusion caused by decreased cardiac output (e.g.: anginal event associated with coronary
3.Cardiogenic
artery disease), severe hypotension, or hypoxemia related to severe anemia or poor oxygen saturation
4.Hemorrhagic Secondary to pathologic cerebrovascular changes within the brain attributable to aging, smoking, hypertension, and hyperlipidemia.
Hematologic and Vascular Mechanisms:
Hyperviscosity or myleoproliferative syndromes (polycythemia, leukemias, or thrombocytosis), vascular obstruction (sickle cell anemia),
Hematologic severe anemia and conditions associated with hypercoagulable states (lupus anticoagulant or antiphospholipid antibody; presence of
Factor V Leiden; or deficiencies of protein C, protein S, or antithrombin III).
Vascular Hypertension leading to thrombosis or bleeding, atherosclerotic emboli from carotid or vertebral plaques, extrinsic compression of
mechanisms cranial vessels (cervical osteophytes, or rotational kinking, tumor), vasospasm (migraine, cocaine) and vasculitis.
TIA Symptoms Preceding Stroke
Individuals experiencing TIA symptoms have been shown to have an 8% to 12% chance of having a stroke within one week and an 11% to 15%
chance of having a stroke within one month.
Stroke Systematic Assessment and Outcomes
The National Institutes of Health Stroke Scale (NIHSS) is a systematic assessment tool that provides a quantitative measure of stroke-related
neurologic deficit. Originally designed as a research tool to measure baseline data on patients in acute stroke clinical trials. Now, the scale is also
widely used as a clinical assessment tool to evaluate acuity of stroke patients, determine appropriate treatment, and predict patient outcome.
Patients with symptoms highly suggestive of stroke are preferentially routed to a hospital that has been certified as a stroke center, as patients with
symptoms of stroke who receive treatment at hospitals with this certification have been shown to have improved outcomes among patients treated for
stroke.
Universal Precautions
Universal precautions are safety procedures designed to prevent transmission of human immunodeficiency virus (HIV), hepatitis B virus (HBV), and
other blood borne pathogens when providing first aid or health care. Under universal precautions, blood and certain body fluids of all patients are
considered potentially infectious for HIV, HBV and other blood borne pathogens. Implementation involves the use of protective barriers such as
gloves, gowns, aprons, masks, or protective eyewear, which can reduce the risk of exposure of the health care worker's skin or mucous membranes
to potentially infective materials. Proper disposal and precautions to prevent injuries caused by needles, scalpels, and other sharp instruments or
devices are also a part of this medical safety practice.
Evaluation of a Patient with Suspected Ischemic Stroke
Time is crucial in evaluation of a patient with suspected ischemic stroke because if given within four-and-a-half hours, intravenous t-PA has proven
benefit in salvaging hypoxic brain tissue. Intra-arterial therapy improves functional outcomes if it can be given within six hours.
Since time is so critical, there is an organized protocol for the emergency evaluation of patients with suspected stroke. The goal is to complete an
evaluation and to decide treatment within 60 minutes of the patient's arrival in the emergency department. A designated acute stroke team includes
physicians, nurses, and laboratory/radiology personnel. All patients with suspected acute stroke are triaged with the same priority as patients with
acute myocardial infarction or serious trauma, regardless of the severity of the deficits.
As for all critically ill patients, the initial evaluation follows the path evaluation and stabilization of the patient's CABs (circulation, airway, breathing).
This is quickly followed by a secondary assessment of neurological deficits and possible comorbidities with the National Institutes of Health Stroke
Scale (NIHSS).
The overall goal is not only to identify people with possible stroke, but also to exclude stroke mimics, identify other conditions requiring immediate
© 2019 Aquifer 2/11
