1. Morbidity and Mortality Conference

2. 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

3. 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

4. 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

5. 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

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

7. Stroke Prevention
USPSTF – ASA for women age 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

8. 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

9. 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

10. Comments & Discussion