diagnosis

Mr. Wright is a 70-year-old male who came to the clinic for checkup after an incident of fall. He states that he felt dizziness, numbness and tingling in his left arm and hand. He is a widower that lives alone and has two daughters and a son that lives nearby. Denies headaches, change in speech or vision, chest pain.

Numbness and tingling in left arm and hand

No incontinence of urine or stool

Some right knee soreness

Visual Disturbances

Slower response to time to questions

Peptic ulcer disease

Dizziness and lightheadedness but no loss of consciousness

PMI (PMI) 5th intercostal space but laterally displaced 3cm

Cataract

Blood pressure: 166/82 mmHg

Family History: Type 2 diabetes mellitus, hypertension, glaucoma

BPH

Left arm weakness

Alcohol consumption

Widowed

History of Essential hypertension (poorly controlled)

Sons lives nearby

Hyperlipidemia (poorly controlled)

Muscle weakness (2/5)

Tachycardia (168 bpm) with irregularly irregular rhythm

Smoking - 1/2 pack per day resumed four years ago after 10-year abstinence

Symptoms resolved after 15 minutes

No current neurological deficits on examination

Age: 70 years

Atrial fibrillation with Irregularly irregular heart rate of 168 beats/minute

LDL 129 mg/dl

(-) JVD bruits

Mr. Wright, a 70-year-old man with uncontrolled hypertension and hyperlipidemia, arrives to the clinic after falling due to an episode of lightheadedness. The associated left hand numbness and vision disturbance subsided after 15 minutes, but there was no loss of consciousness. The physical exam is notable for tachycardia, irregularly irregular heart rhythm, and increased blood pressure.

Dizziness and lightheadedness but no loss of consciousness

Blood pressure: 166/82 mmHg

Numbness and tingling in left arm and hand

No current neurological deficits on exam

Visual disturbances

LDL 129 mg/dl

Symptoms resolved after 15mins

Tachycardia

History of essential hypertension (poorly controlled)

Atrial Fibrillation with irregularly irregular heart rate of 168 beats/minute

Smoking

Age: 70 years

Dizziness and lightheadedness but no loss of consciousness

Blood pressure: 166/82 mmHg

Numbness and tingling in left arm and hand

LDL 129 mg/dl

Visual disturbances

Tachycardia

Smoking

Atrial Fibrillation with irregularly irregular heart rate of 168 beats/minute

Race: African American (more likely to have stroke) (Cash, et. al., 2021)

Slower response to time to questions

Dizziness and lightheadedness

EKG finding: Atrial Fibrillation with LVH, inferior and lateral ST depression

Visual disturbances

Irregularly Irregular rate of 168 beats/min

Hypertension

Tachycardia: HR: 118

EKG

Evaluation of dysrhythmia (Cash, et al., 2021)

Brain imaging with head CT and/or MRI

For individuals with TIA, brain MRI using diffusion-weighted imaging is more sensitive than CT at finding small infarcts. Additional data from multimodal CT and MRI tests may help in ischemic stroke diagnosis.

CBC and PT/PTT

Infectious, hypoxic/hypoperfusion, thrombotic, and hemorrhagic etiologies should be taken into consideration when the CBC and PT/PTT are abnormal. To obtain baseline before starting antithrombotic drug.

Cardiac Markers

Since myocardial ischemia is a potential side effect of acute cerebrovascular illness, markers for cardiac ischemia are crucial for all patients with suspected ischemic stroke.

Glucose check

Rule out hypoglycemia

B-type Natriuretic Peptide (BNP)

An increased level can indicate acute stroke.

Oxygen Saturation

The cause of a stroke may be underlying CAD, and by maintaining normal oxygen saturation, the severity of brain damage may be reduced. Stroke patients who are hypoxic need supplemental oxygen.

Rapid transfer to hospital

Emergent situation, higher acuity of care (MRI)

Antiplatelet Therapy once bleeding is ruled out

It lowers the likelihood of clot formation (Fox, 2019). Aspirin is the preferred platelet inhibitor. For patients who can't take aspirin, most providers reserve clopidogrel and utilize it as a last resort. Based on patient preference, the predicted risk of bleeding if anticoagulation is used, and access to high-quality anticoagulation monitoring, it is advised for low-risk and certain moderate-risk patients with AF. The suggested dose is 81 mg because greater doses, such 325 mg, increase adverse effects without significantly lowering the risk of stroke.

Antihypertensive

Blood pressure lowering to a goal of 130/80 mmHg using antihypertensive (Thiazide-like Diuretic: Hydrochlorothiazide + Amlodipine + Metoprolol 25 mg PO daily)

In people who have had an ischemic stroke and are past the hyperacute stage, antihypertensive therapy is advised for the prevention of recurrent stroke and other vascular problems. Based on its extended half-life and demonstrated decrease of CVD in clinical trials, hydrochlorothiazide is chosen. Keep an eye on uric acid and calcium levels, as well as hyponatremia and hypokalemia. Metoprolol and Amlodipine are introduced for better control (the patient has already been taking them) (to control his heart rate as well).

Lipid control (High intensity Statin therapy: Atorvastatin 40 mg daily)

All patients with a history of TIA or CVA should be placed on high-intensity statin such as atorvastatin 40 or 80 mg or rosuvastatin 20 mg

Educate on medication adherence

Management of associated risk factors

Reduce alcohol consumption

Decrease or eliminate risk factors (Cash., et. al., 2021)

Smoking Cessation

Smokers who have had an ischemic stroke or transient ischemic attack should be strongly advised not to smoke.

Stroke Education

Stroke education including knowledge of stroke warning signs and need to call 911 in the event of a cerebrovascular event as well as awareness of individual’s own risk factors.

Diet

All people are advised to follow a Mediterranean diet by the ACC/AHA Lifestyle Guidelines in order to lower their risk of ASCVD. Additionally, people with hypertension need to keep their daily sodium consumption to 2,400 mg or fewer.

Exercise plan to reduce weight

All adults are urged to engage in physical exercise of moderate to vigorous intensity three to four times per week for a total of forty minutes, based on moderate quality evidence. It is advised to follow a supervised rehabilitative exercise program for people who have disabilities following an ischemic stroke.