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Family Medicine 22: 70-year-old male with new-onset unilateral weakness

Family Medicine 22: 70-year-old male with new-onset unilateral weakness

Nursing Experts

Family Medicine 22: 70-year-old male with new-onset unilateral weakness

Family Medicine 22: 70-year-old male with new-onset unilateral weakness

Author: George Nixon, MD; Associate Editor: John B. Waits, MD, FAAFP; Case Editor: Lacy Smith, MD

INTRODUCTION

HISTORY
You review the patient schedule with Dr. Wilson.

It is late autumn and you are working at Dr. Wilson’s office.

Dr. Wilson looks over his patient schedule and asks you to see Mr. Glenn Wright, a 70-year-old man who has been a patient in Dr. Wilson’s practice for six years. Today, he is listed as a “walk-in” visit.

You knock, and then enter to begin this patient encounter. It is 3:15 p.m.

HISTORY OF PRESENT ILLNESS

HISTORY
You interview Mr. Wright.

You introduce yourself and begin the interview while also reviewing the EMR which displays the following chief concern: “Fell down and couldn’t get up.” Family Medicine 22: 70-year-old male with new-onset unilateral weakness.

MEDICAL, FAMILY AND SOCIAL HISTORY

HISTORY

You ask,

You are concerned Mr Wright may need urgent evaluation so you proceed rapidly with focused questions.

You learn the following: Mr. Wright has some right knee soreness, but denies weakness, headache, current vision or speech problems, chest discomfort, palpitations, shortness of breath, nausea, abdominal pain, and incontinence of urine or stool.

You scan his chart in the EMR.

Summary of most recent progress note:

Date: Four months prior.

Chief Concern: Follow-up hypertension & hyperlipidemia

Subjective: Persistent stiffness in knees, but pain relieved with acetaminophen. Urine flow improved. Denies exertional chest discomfort, decreased stamina, headaches, dizziness and weakness. Occasionally omits diuretic and statin. Family Medicine 22: 70-year-old male with new-onset unilateral weakness.

ROS: Occasional dizziness and decreased energy for 2 to 3 months. Decreased night vision. Occasional heartburn, stiff back and knees. Denies fever, syncope, headache, weight loss, abdominal discomfort or change in bowel habits or stool.

Past Medical History: Essential hypertension, osteoarthritis, peptic ulcer disease, benign prostatic hyperplasia, hyperlipidemia, cataracts, shingles. No surgery.

Family History: Type 2 diabetes mellitus, hypertension, glaucoma.

Social History: Widowed for four years, retired railroad worker. Children: two daughters out-of-state and a son who lives nearby. Smoking – 1/2 pack per day resumed four years ago after ten-year abstinence. Alcohol – single shot whiskey most nights. Hobbies – quail hunting and fishing.

Medications: Hydrochlorothiazide 25 mg daily, amlodipine 10 mg daily, doxazosin 2 mg every evening, simvastatin 20 mg every evening, over the counter ranitidine, acetaminophen.

Allergies: No known allergies.

Immunizations: H zoster, pneumococcal, Tdap, and influenza vaccines current.

Objective: Blood pressure 166/80 mmHg. No carotid bruits. Lungs: Clear. Heart: Regular rhythm. Rate 70’s beats/minute, point of maximal impulse (PMI) laterally displaced. Family Medicine 22: 70-year-old male with new-onset unilateral weakness.

Labs: Fasting lipid profile: total cholesterol 190 mg/dl, HDL 31 mg/dl, LDL 129 mg/dl, triglycerides 150 mg/dl.

Assessment: Hypertension – poorly controlled, hyperlipidemia – poorly controlled, osteoarthritis of the knees, benign prostate hyperplasia. Family Medicine 22: 70-year-old male with new-onset unilateral weakness.

Plan: Follow-up 6 to 8 weeks.

Discussed importance of medication compliance, smoking cessation, and lifestyle changes on personal health risks for stroke, heart, and kidney disease. Given DASH Diet brochure and prescription coupons.

You confirm this past medical history, family history, and social history with Mr. Wright.

Question

Given Mr. Wright’s history of dizziness, visual symptoms, left arm numbness, and imbalance,

is on your differential along with several cardiovascular disorders. What risk factors does Mr. Wright have for cerebrovascular and cardiovascular disease (ASCVD)?

The suggested answer is shown below.

 

Letter Count: 965/1000

Answer Comment

Age over 45 years

Smoking history

Hypertension

Hyperlipidemia

TEACHING POINT

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. Family Medicine 22: 70-year-old male with new-onset unilateral weakness.

References

Easton JD, Saver JL, Albers GW, et al. Definition and evaluation of transient ischemic attack: a scientific statement for healthcare professionals from the American Heart Association/American Stroke Association Stroke Council; Council on Cardiovascular Surgery and Anesthesia; Council on Cardiovascular Radiology and Intervention; Council on Cardiovascular Nursing; and the Interdisciplinary Council on Peripheral Vascular Disease. The American Academy of Neurology affirms the value of this statement as an educational tool for neurologists. Stroke 2009;40(6):2276-2293.

ORTHOSTATIC VITALS

PHYSICAL EXAM
You perform the TUG test on Mr. Wright.

While washing your hands, you tell Mr. Wright that you will be performing a physical and neurologic exam.

You begin the exam testing for orthostatic changes.

Orthostatic Vital Signs

Position – Supine:

    • Heart rate: 110 beats/minutes
    • Blood pressure: 166/82 mmHg

Position – Standing:

    • Heart rate: 120 beats/minute
    • Blood pressure: 162/80 mmHg
TEACHING POINT

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). Family Medicine 22: 70-year-old male with new-onset unilateral weakness

References

Consensus statement on the definition of orthostatic hypotension, pure autonomic failure, and multiple system atrophy. Orthostatic changes. J Neurol Sci. 1996;144:218-219.

TIMED UP AND GO TEST

PHYSICAL EXAM
You perform the TUG test on Mr. Wright.

You then proceed to assess Mr. Wright’s general balance, mobility, and risk for fall by having him perform the (TUG test) “Timed Up and Go” test.

You know that it is important to screen rapidly patients who present with neurologic symptoms. Clinical findings can change quickly, and the establishment of a baseline provides a comparative benchmark.

TEACHING POINT

Timed Up and Go Test

Measures mobility and fall risk in people who are able to walk on their own. The person may wear their usual footwear and can use any assistive device they normally use. Family Medicine 22: 70-year-old male with new-onset unilateral weakness.

Instructions to the patient:

    1. Sit in the chair with your back to the chair and your arms resting in your lap.
    2. Without using your arms, stand up from the chair and walk 10 ft. (3m).
    3. Turn around, walk back to the chair, and sit down again.

Timing begins when the person starts to rise from the chair, and ends when he or she returns to the chair and sits down. The person should be given one practice trial and then three actual trials. The times from the three actual trials are averaged.

Prediction of Mobility

Average Number of Seconds for TUG

Mobility Prediction

<10

Freely mobile

< 20

Mostly independent

20-29

Variable mobility

> 30

Impaired mobility

Note: This test is more discriminative in patients who are more debilitated.

TEACHING POINT

Initial Physical Exam of Neurologic Symptoms

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Exam of cranial nerve VII

Facial asymmetry is not specific for stroke as it can also be caused by Bell’s Palsy or Horner’s syndrome. Weakness or asymmetry of the muscles of facial expression (CN VII) is a common presenting sign of stroke.

Auscultation of carotids

Listen for carotid bruits as emboli from carotid arteries are associated with TIA and stroke and these emboli may result in transient monocular blindness or visual field defects.

Romberg

Ischemic blood flow in the vertebrobasilar system is associated with ataxic gait and instability of balance that may be revealed with Romberg testing.

Cardiopulmonary

The presence of murmurs or irregular rhythms on thecardiovascular exam may signal valvular disease and intra-cardiac mural thrombi as sources for cardiac emboli.

Gross visual fields

Emboli from carotid bruits are associated with TIA and stroke and these emboli may result in transient monocular blindness or visual field defects.

Proprioception

Proprioceptive and spatial deficits are present in patients who have suffered brain ischemia affecting the sensory areas.