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43. You are seeing a 75-year-old woman with a history of type II diabetes mellitus who came to the emergency department because of a left facial droop, slurred speech, difficulty swallowing, and decreased balance. She woke up the day prior to admission feeling lightheaded. She had no palpitations, diaphoresis, or visual changes. She went back to bed and at noon awoke with difficulty swallowing and a sensation of her left tongue tingling. Her daughter noted softer speech with a left facial droop. The patient complained of difficulty with balance that made walking very difficult. She had no vertigo and ate without difficulty. Today she had worsened difficulties with left facial droop, difficulty swallowing, tongue tingling, and her daughter also noticed slurred speech. There are no complaints of word finding difficulties, no dysesthesia, and no headaches. Her blood pressure is 180/75 mm Hg and pulse is 65/min. She has a normal mental status examination with slurred speech. Physical examination shows weakness and decreased sensation of the left lower face. The next most appropriate action is to
A. check a glucose finger stick and send routine chemistries, cell counts, and urinalysis
B. order a brain MRI
C. order a cerebral angiogram
D. start her on heparin
E. start her on prednisone and acyclovir
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B) although whoever comes to ER we will get chemistery/UA/CBC .but in this case the whole scenario is based on the progressive brain stem stroke which has been getting worst and since she had high BP and headache prior to the event I am worried about any bleeding in the brain stem which has a very poor prognosis and we should start manitol and decatron with the early signs of the brain herniation and swelling....
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This is the commonest mistake we always make:
The correct answer is A. One of the most common causes of neurological deficit in elderly patients is a toxic or metabolic disturbance. Hypoglycemia is particularly common in patients who are being treated for diabetes. These problems are often easily correctible if caught early. Therefore, a basic medical screen should be done immediately.
Stroke is certainly a possibility in this case. Brain MRI (choice B) would be the best test for this, however it can take a while to get this done and you should first evaluate for toxic/metabolic disturbances.
A cerebral angiogram (choice C) would be indicated if you had strong suspicion for an aneurysm or vascular malformation. There is no reason to believe one of these is causing her symptoms.
There is no indication to start her on heparin (choice D). She may even have an intracranial hemorrhage causing her symptoms. If this were the case starting heparin might kill her.
Prednisone and acyclovir (choice E) are the treatment for Bell palsy. Her facial weakness is not the pattern of Bell palsy and Bell palsy does not cause sensory impairments.
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the vital signs and facial droop made me pick MRI....I thought with hypoglycemia I should have tachycardia and low BP and diaphoresis...
