HPI:
81 year-old RH Asian woman with Ischemic Cardiomyopathy (EF 40%), Hypertension,
Hypothyroidism, Diabetes Type II, and Prior CVA with residual left-sided hemiparesis
was in her usual state of health until 8am today, when she was noted to have an
episode of slurred speech. Specifically, she awoke in the morning feeling well. She got
up to use the bathroom and while walking noticed a feeling of dizziness. She denies the
room spinning, no tinnitus, no dysarthria or dysphagia. Her visual field constricted
slightly and she called out to her husband. He noted that she didn’t “sound right”, but
found her sitting down on the floor comfortably. She was able to engage in normal
conversation and she began to feel better. EMS arrived and bp was 80/40, glucose 52.
She was noted to have mild left-sided weakness so she was brought to ER. She was
able to get up and walk herself into the ambulance.
ROS:
Pt denied focal weakness, numbness, and headache.
Pt. denies chest pain, palpitations, shortness of breath.
No recent fever, cough, diarrhea, constipation, urinary symptoms, rash, or weight loss.
She recently had one of her blood pressure medications (“the water pill”) increased.
PMH:
1. ischemic cardiomyopathy – 2D Echo May 2011 systolic function mildly reduced
(EF 40%), mild anteroseptal hypokinesis, concentric left ventricle hypertrophy,
and Grade II diastolic dysfunction. Pt had MI in 2004, no stenting.
2. hypertension – controlled.
3. hypothyroidism – last TSH August 2011 1.4.
4. DM II – A1C August 2011 6.5.
5. Prior CVA – Pt presented in 2004 with MI and had left-sided facial/arm
weakness. Found to have ischemic stroke R MCA territory (superior division).
Holter no atrial fibrillation. 2D Echo no thrombus. No TEE done. Carotids no
significant stenosis. MRA showed diffuse irregularities in large cerebral arteries.
Inflammatory workup negative. Pt discharged on aspirin & plavix, completed
rehabilitation, had mild residual left arm weakness.
MEDS:
Clopidogrel 75mg PO daily
Carvedilol 12.5mg PO twice daily
Lisinopril 20mg PO twice daily
Metformin 500mg PO twice daily
Crestor 20mg PO daily
Levothyroxine 125mcg PO daily
Furosemide 40mg PO twice daily (recently increased from 20mg PO twice daily)
ALLERGIES:
None
FAMILY HISTORY:
Mother – diabetes type II
Father – HTN, CAD
Two brothers alive and well, HTN
Three children alive and well
SOCIAL HISTORY:
Born in China, moved to U.S. in 1980. Worked as a fabric technician until age 60.
Currently married, retired, living with husband. No toxic habits.
PHYSICAL EXAMINATION:
Bp 140/75, pulse 65 (regular)
No carotid bruits, no cardiac murmurs
Lungs clear, abdomen soft/NT
MS: A&O * 3, speech fluent, language intact
CN: PERRL, EOMI, mild left nasolabial flattening evident on driver’s license picture from
2005; no facial numbness; tongue midline, palate symmetric
MOTOR: 5/5 throughout except 4+/5 left deltoid, triceps and wrist extension, with
decreased amplitude of fine finger movements on that side, mild pronator drift. Tone is
slightly increased in left upper extremity, otherwise normal throughout.
REFL: 2+ throughout except 3+ left upper extremity; toes downgoing bilaterally
COORD: finger nose finger and heel to shin intact bilaterally; no tremor
GAIT: narrow base, normal stride, normal turn, normal armswing
NIHSS: 1 (nasolabial flattening)
LABS / IMAGING:
CT Brain today: No acute changes. Chronic R MCA territory encephalomalacia.
Coags wnl.
CBC wnl.
CMP wnl.
ASSESSMENT & PLAN:
81 year-old RH Asian woman with Ischemic Cardiomyopathy (EF 40%), Hypertension,
Hypothyroidism, Diabetes Type II, and prior CVA with minimal residual left-sided
hemiparesis presents with transient slurred speech in the context of syncopal symptoms
upon standing, without new focal neurological symptoms, in the context of recent
increase in dose of diuretic. Exam demonstrates only minimal left nasolabial flattening
and minimal left upper extremity weakness in an upper motor neuron pattern (NIHSS
1). MRI from 2004 showed irregularities and narrowing diffusely throughout the large
arteries in the bilateral anterior and posterior circulation, with the greatest area of
stenosis approximating 40% at the M1 segment of the R MCA.”
1. transient slurred speech – Differential diagnosis includes metabolic reactivation of old
stroke symptoms, new TIA, partial seizures and migraine. Pt initially presented with
slurred speech and left-sided weakness and endorses similar symptoms now, which
resolved after sitting down and which occurred during standing, which suggests there
may be an orthostatic component. She was shown to have mild intracranial artery
disease on last MRI, so she may have intracranial atherosclerosis, which becomes
symptomatic upon rapid standing. Recommend STAT MRI/MRA brain to rule out acute
stroke. No intervention as patient is not in time window. Also recommend repeating 2D
Echo, carotid ultrasound (not done since 2004). No suggestion of seizure activity but
we may consider EEG if remainder of workup is negative or seizure is further
suspected. No personal or family history of migraine. Agree with medication
adjustment for low BP and CHF optimization. Neuro to follow.