Case Scenario: A 62-year-old, African American male presents to the emergency department by ambulance with his wife accompanying him. He states that he fell off his ladder while putting up Christmas lights and then became unconscious. His wife initially thought he had a concussion, but then noticed drooping on the left side of his face and thought it was best to come to get it checked out. There is a noticeable droop on the left side of his face, slurred speech has developed, and complaints of sudden vision problems. Cheyne-stokes respiration pattern is noticed.

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Age? 62 years old

Ethnicity? African American

Gender? Male

Chief Complaint?

“I have a really bad headache and have noticed my vision is getting blurry from my left eye. The left side of my face feels kinda numb and I am having a hard time trying to move any of my left facial muscles."

HPI?

Past Medical History?

Hypertension (ongoing) – diagnosed at 28: takes Metoprolol, Amlodipine, and aspirin daily

Hyperlipidemia (ongoing) – Diagnosed at 34: takes Rosuvastatin daily

Atherosclerosis (ongoing) – diagnosed at 47: takes Warfarin daily

Atrial fibrillation (ongoing) – diagnosed at 58: takes Amiodarone daily

Surgical History?

Kidney stones removed at age 23

Family History?

Mother (living) has history of diabetes

Father (living) has history of hypertension

Children: none

O: I didn't have a headache until after I woke up from falling. When I first got up it was pretty sudden, but has gradually gotten worse.
L: It's really only hurting badly in my head, but I'm noticing some tingling in my hands and legs.
D: My headache and noticeable facial dropping about 45 minutes ago and the tingling started during the car ride about 20 minutes ago.
C: I would describe the tingling in my hands and legs as static. My head feels as though its foggy and I'm losing sensations.
A: After falling, my wife thought I had a concussion so I tried resting. Other than resting in a dark room, I haven't tried anything else to alleviate the pain. We thought coming here was my best option for that.
R: The pain is only in my head, I only feel the tingles in my hands and legs. Everything else just feels numb.
T: The pain has been consistent since I woke up from being unconscious. the tingles didn't start until the car ride to the hospital.
S: I would rank my pain in my head as 8. The tingles don't hurt but they are uncomfortable, so I would say a 3.

Social History?

Drinks: Occasional drink throughout the week, about 4 times a week.

Smokes: Patient smokes 2 packs a week

Illicit drugs: None

Living situation: lives with wife in suburbs

Occupation: retired at 60, worked as electrician

Diet: does his best to eat foods low in cholesterol, stays away from sugary drinks, tries to drink mostly water, eats out 4x a week. Has had more of an appetite lately.

Exercise: hasn't been active since retirement

Medications?

takes Metoprolol, Amlodipine, and aspirin daily

takes Warfarin daily

takes Amiodarone daily

takes Rosuvastatin daily

Allergies?

bees – develops hives, diagnosed at age 6
latex – develops rash, diagnosed at age 6

Vaccination Status?

COVID-19 (Pfizer) vaccine x2 and booster done at age 60

up to date on all other vaccines

List of Potential Diagnoses

Review of Systems

Physical Exam

Diagnostic Results

Case Reveal and Discussions

Positives

Genitourinary: No complaints regarding urination

Reproductive: Denies any reproductive issues

Skin: Denies changes in the skin (i.e. rashes, redness, itchiness, flaking)

Endocrine: Denies having problems with glucose levels or thyroid problems despite family history

Lymph Nodes: Denies any pain or difficulty swallowing

Respiratory: Denies any respiratory problems

Cardiovascular: Denies problems with heart health

Negatives

Musculoskeletal: muscle weakness, lack of coordination, occasional weakness on one side of the body, weakness in facial muscle

Vision: blurred vision

Neurological: occasional mental confusion and reduced sense of touch, lightheadedness, severe headaches

Gastrointestinal: constipation and dysphasia

Constitutional: Complaints of occasional fatigue

Positives

General Appearance: Appropriate hygiene and dress

Skin: No changes in skin pigment or texture

Pelvic: No pelvic pain

Lungs: Normal lung function

Cardiovascular: No heart problems or abnormalities

Negatives

Abdominal: tightness, pressure in gut

MSK: muscle weakness in limbs

Neurological: numbness in face and neck pain

Extremities: loss of blood circulation in limbs

Vision: blurred vision

Vital Signs

Oral Temp: 37ºC

Pulse: 98 bpm

RR: 24 breaths per minute

BP: 162/93

Weight: 225 lbs

Height: 6’1”

3) Diffuse Axonal Injury (DAI)

4) Complex Concussion

6) Subdural Hematoma

2) Ischemic Stroke

1) Hemorrhagic Stroke

5) Epidural Hematoma

7) Traumatic Subarachnoid Hematoma

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Multimedia Aspect for ROS:

Multimedia Aspect for Physical Exam