Morbidity and Mortality Conference

Case: Brief Admission HPI 86 yo female eating lunch with friends slumped over and was unable to respond, alert and drooling EMS called and brought to ER 11 minutes after onset of event R side flaccid, unable to answer questions

Case: PMH – HTN, Hypothyroid, Osteoporosis FH – CVA, MI, Dementia SH – quit smoking 1965, occ etoh Medications - Norvasc, atenolol, hydralazine, dyazide, synthroid, asa, vitamins Allergies - NKDA

Case: Physical exam Labs: Na+ 131, Glucose 129, rest normal Vitals – 123/71, P68, T36, R16 Pulse ox 98%, BMI 20 R sided hemiparesis NIH stroke scale score of 30 Labs: Na+ 131, Glucose 129, rest normal CT: slow flow in L middle cerebral artery

Timeline of Events Date/Time Clinical Status/ change in status 14:40 Slumped and unable to response at lunch 14:51 Arrived in ER 15:25 TPA given Admitted to ICU 17:05 Stat MRI, L cerebral artery occlusion with ischemic stroke Evening Seen by neurology, paroxysmal afib Cardiology eval next am, amiodorone Discharged to rehab with feeding tube a few days later

Risk Factors for Stroke Age HTN Heart Disease/Diabetes Afib Hypercoagulability Prior Stroke/TIA Smoking

Stroke Prevention USPSTF – ASA for women age 55-79 when reduction in ischemic stroke outweighs risk of GI bleed USPSTF – do not prescribe combined estrogen/progesterone for prevention Control of SBP – goal < 140; lower with renal disease, possibly diabetes

Adverse events/outcomes triggering case presentation Yes No Unexpected death X Medical or surgical complication Delay in care Delay in Diagnosis Prolonged medical care in setting of poor prognosis Other

Our patient BP at last visit – 177/84, 161/83, but hadn’t taken medicine – nurse visit 5 days later for BP check on meds 127/72 and 122 on presentation to ER LDL on 6/3 – 99, HDL – 67 On asa 81 mg daily, not on HRT

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