FULL CODE CASE

DISCUSSION:

SLURRED SPEECH
GROUP -5B
Preceptor: Dr.Christine Joy Raquid
 GENERAL DATA

Name: J.G
Age: 59 years old
Sex: male
Religion: not mentioned
Address: not mentioned
Civil status: married
Occupation: not mentioned
 CHIEF COMPLAINT

“SLURRED SPEECH”
 HISTORY OF PRESENT ILLNESS

Few hours prior to consultation patient started experiencing slurred

speech along with right sided weakness, his wife mentioned that
patient was found lying on ground with near complete right sided face,
arm and leg weakness. Hence prompted to seek consultation.
PAST MEDICAL HISTORY:
• Patient is hypertensive,
• Patient has hyperlipidemia
• Patient had undergone appendectomy

FAMILY HISTORY : Not contributory

PERSONAL AND SOCIAL HISTORY :

• Non alcoholic
• Non allergic
• Patient was a smoker, quit smoking 5 years ago.
 REVIEW OF SYSTEMS
Unable to obtain due to expressive and receptive aphasia

 General: (-) fatigue, (-) Night sweats, (-) weight gain, (-) chills, (-) fever

 Skin: (-) itching, (-) rashes, (-) pruritus, (-) wounds

 Head: (-) palpable masses, (-) lesions, (-) headache, (-) head injury

 Eye: (-) visual changes, (-) eye pain, (-) double vision, (-) visual loss

 Ear: (-) ear pain, (-) hearing problem, (-) discharges, (-) deafness

 Nose: (-) Runny nose, (-) sinus pain, (-) epistaxis, (-) post nasal drip
 Mouth: (-) dry lips & mouth, (-) bleeding gums, (-) tonsillitis, (-) sore throat

 Neck: (-) lumps, (-) swollen glands, (-) stiffness of neck, (-) limitation in motion

 Pulmonary system: (-) cough, (-) sputum, (-) dyspnoea, (-) haemoptysis

 Cardiovascular: (-) chest pain, (-) exercise intolerance, (-) Orthopnoea, (-) palpitations

 Gastrointestinal: (-) abdominal pain, (-) difficulty swallowing, (-) nausea, (-) vomiting

 Genitourinary: (-) frequency in urination, (-) dysuria, (-) flank pain, (-) no penile discharge.
 Neurological: (-) confusion, (-) seizures, (-) nervousness (-) focal motor or sensory loss

 Haematological: (-) anaemia, (-) bleeding disorders, (-) purpura

 Musculoskeletal: (-) leg pain, (-) myalgia, (-) arthralgia, (-) swelling

 Psychiatric: (-) delusions, (-) depression, (-) hallucinations, (-) anxiety

 Endocrine: (-) excessive sweating, (-) heat or cold intolerance, (-) thyroid problems, (-)
diabetes
 PHYSICAL EXAMINATION
• General status: slurred speech, right sided droop, GCS 13
• Vital signs:
o Heart rate: 88 bpm
o Blood pressure :175/89mmHg
o Respiratory rate :18/min
o Temperature: 37 ⁰C
o Height: 179 cm
o Weight: 83 kg

 Airway: Patent without obstruction or stridor.

 Breath: Bilateral, symmetric breath sounds with normal chest rise.
 Circulation: 2+ peripheral pulses, normal capillary refill.
 Skin: warm and dry, no rashes.
 HEENT: normocephalic, atraumatic, PERRL (Pupils equal round and reactive to light), EOMI
(Extraocular movements intact), oropharynx is clear. There is right sided facial droop.
 Neck: no masses, trachea midline, supple with full range of motion without C-spine
tenderness.
 Cardio: irregularly irregular, no murmurs, rubs, or gallops.
 Pulmonary: clear to auscultation bilaterally, no retractions, no wheezes, Ronchi, or rales.
 Abdominal: soft, nontender, nondistended, normal active bowel sounds, no percussion
tenderness, rebound or guarding.
 Genito urinary: normal penis and testicles, no masses, no hernias.
 Back: no costovertebral angle tenderness, no tenderness to the thoracic or lumbar spine.
 Musculoskeletal: no clubbing, cyanosis or edema, normal range of motion without bony point
tenderness.
 Neurological: somnolent, unable to follow commands. 2/5 strength in right face and arm, 3/5
strength in the right leg with aphasia. No blink to visual threat on right.
 Psychiatric: unable to cooperate.
 SALIENT FEATURES
59-year-old male
Slurred speech
Right side weakness 8 in arms, legs and face
Hypertension
Hyperlipidemia
Remote appendectomy
Former smoker, quit 5 years ago
Bp: 175/90 mm Hg
Finger stick blood sugar: 122mg/ dl
Capillary PE : +2 peripheral pulse
Cardiac PE : irregularly irregular rhythm
Neurologic PE: somnolent, unable to follow commands. 2/5 strength in the right face and arm,3/5 strength
in the right leg with aphasia. No blink to visual threat on right.
ECG: Atrial fibrillation at 90 bpm
MRI: There is an acute infarct in the distribution of the left middle cerebral artery.
 IMPRESSION

“ ISCHEMIC STROKE”
 DIFFERENTIAL DIAGNOSIS
Diagnosis Rule in Rule out

Hemorrhagic stroke (+) slurred speech, (+)unilateral in CT and MRI shows no mass or
weakness hemorrhage,(-) headache

Subdural hemorrhage (+)slurred speech, (+) motor and no sign of trauma ,(-)headache, in
sensory deficit Ct no mass or hemorrhage

Intracerebral hemorrhage (+)right sided weakness,(+) (-)headache, in Ct no mass or

slurred speech.(+) hypertension. hemorrhage

Vertebral artery dissection (+) right sided weakness (-) hoarseness, (-)vertigo, nausea
and vomiting,(-) contralateral loss
of pain.
DIAGNOSTIC TEST
PATHOPHYSIOLOGY
 NAME: J.G
ELEVATED TOTAL CHOLESTROL, ELEVATED AGE: 59 YEARS OLD
ANTIHYPERTENSIVE
LDL, LOW HDL CHOLESTROL, ELEVATED GENDER: MALE
DRUG - CANDESARTAN
TRIGLYCERIDES - HYPERTENSIVE
- HYPERLIPIDEMIA
- PREVIOUS SMOKER
IRREGULARITY – IRREGULAR HEART RATE AND
VENTRICULAR ARRYTHMIA, TACHYCARDIA RHYTHM

ANEMIC IN HEMOGLOBIN AND HEMATOCRIT THROMBOTIC EMBOLISM, OCCULSION,

TEST RESULT SYSTEMIC HYPOPERFUSION

ANTITHROMBOTIC DRUG ALTE PLASE

ACUTE OCCULSION OF AN INTRACRANIAL
ASPIRIN – ANTIPLATELET AGENT CLOPIDOGRAL VESSEL
– ANTIPLATELET AGENT
CAUSES REDUCTION IN BLOOD FLOW TO THE
BRAIN REGION
 SUPPLY OF OXYGEN RESTRICTED AND
REDUCED TO BRAIN

IF THE BLOOD SUPPLY TO BRAIN IS 16-18ml/100g TISSUE PER MINUTE CAUSE INFARCTION.
<20 ml/100g TISSUE PER MINUTE CAUSE ISCHEMIC WITHOUT INFARCTION

DECREASE IN CEREBRAL BLOOD FLOW TO ZERO CAUSE DEATH

OF BRAIN TISSUE WITHIN 4 – 10 MINUTE

FAILURE OF MITOCHONDRIA TO
PRODUCE ATP

MEMBRANE ION PUMP STOP

FUNCTIONING
 NEURONE DEPOLARIZE

INTRACELLULAR ca+ INCREASE

INCREASE IN EXTRACELLULAR k+

ACCUMULATION OF GLUTAMATE IN
EXTRACELLULAR SPACE

NEUROTOXICITY
 DAMAGE TO NEURON
CT SCAN OF CRANIUM
HYPODENSE ISCHEMIA AT THE
RIGHT PARIETOTEMPORAL
REGION OF THE BRAIN.
CELL DEATH (APOPTOSIS)

ACUTE ISCHEMIC STROKE

CENTRAL CRANIAL NERVE VII

DEVIATION OF EYES AFFECTED IN BRAIN

LOWER FACIAL DROOP ON LEFT SIDE

RIGHT GAZE DEVIATION

 ACUTE ISCHEMIC STROKE

INFARCTED CEREBRAL ARTERY CEREBRAL HEMISPHERE AFFECTED

GRAY AND WHITE MATTER AT THE SITE OF

INFARCTION ARE ABRUPTLY DESTROYED UPPER MOTOR NEURONS AFFECTED

HEMIPARESIS
AT BROCA’S AREA

LEFT CEREBRAL HEMISPHERE

BROCA’S ASPHYXIA AFFECTED
SEVERE IMPAIRMENT IN WORD
RIGHT SIDED HEMIPARESIS
FLUENCY, NAMING, REPETITION

RIGHT SIDED ARM, FACE, EXTREMITY

SPEECH DIFFICULTY WEAKNESS
 PHARMACOLOGICAL
MANAGEMENT
● IV access with two peripheral IV lines (avoid arterial or central line placement)
● Review eligibility for Tissue Plasminogen Activator(tPA)
● Frequent blood pressure monitoring
● No other antithrombotic treatment for 24 hours.
 Drug Drug Classification Mechanism of Dosage, Rate and Common side effects
Action Frequency

Alteplase Antithrombotic Alteplase binds to 0.9mg/kg (not to Nausea, vomiting,

enzyme fibrin in a blood exceed 90mg total bleeding.
clot and activates dose)
the clot-bound 10% of the total
plasminogen, dose given as a
causing the blood bolus (one-time
clots to break dose) over 1
down and dissolve. minute
the remaining 90%
is infused (given
over) over 60
minutes
Aspirin Anticoagulants, Aspirin is a salicylate that Aspirin 325mg Anemia,
Antiplatelets exhibits analgesic, anti- orally should begin thrombocytopenia,
and Fibrinolytics inflammatory, and within 24 to 48 vomiting, dizziness.
antipyretic activities. It is hours of an
a selective and ischemic stroke,
irreversible inhibitor of but not within 24
cyclooxygenase-1 (COX-1) hours of
enzyme resulting in direct completion of
inhibition of the alteplase therapy.
biosynthesis of  
prostaglandins and
thromboxanes from
arachidonic acid.
Additionally, it also
inhibits platelet
aggregation.
 NON PHARMACOLOGICAL
TREATMENT
Healthy lifestyle is fundamental for non-pharmacological stroke prevention and
includes:
 Healthy diet
 Regular physical activity
 Low-normal body mass index
 Smoking abstinence and
 Moderate drinking of alcohol
 SURGICAL MANAGEMENT
1. Brain Bypass Surgery:

A cerebral bypass is the brain's equivalent of a coronary bypass in the heart. The surgery
connects a blood vessel from outside the brain to a vessel inside the brain to reroute blood
flow around a damaged or blocked artery. The goal of bypass surgery is to restore blood
supply to the brain and prevent strokes.

2. Cerebral angioplasty:

Cerebral angioplasty is similar to a widely used cardiology procedure and is used to open
partially blocked vertebral and carotid arteries in the neck, as well as blood vessels within
the brain.
ALGORITHM
 FINAL DIAGNOSIS

ISCHEMIC STROKE:
Ischemic stroke is characterized by the sudden loss of blood circulation to an area of
the brain, resulting in a corresponding loss of neurologic function. Acute ischemic
stroke is caused by thrombotic or embolic occlusion of a cerebral artery and is more
common than hemorrhagic stroke.
Full code case has Mr. J with history of hypertension, hyperlipidemia, Atrial fibrillation,
was smoker in past.... These factors are encouraging for ischemic stroke , besides ECG
showed Atrial fibrillation, mri showed acute infarct in LMCA, patient has slurred
speech and right sided weakness this clinical manifestations and lab results highly
suggest it to be Acute Ischemic stroke.
THANK YOU.....