What is the appropriate workup for a patient presenting with fatigue, feverishness, and right-sided numbness upon waking?

Workup for Fatigue, Feverishness, and Right-Sided Numbness Upon Waking

The patient presenting with fatigue, feverishness, and right-sided numbness upon waking should undergo immediate brain imaging with MRI to rule out acute ischemic stroke, as these symptoms strongly suggest a cerebrovascular event affecting the left hemisphere. 1

Initial Assessment and Urgent Evaluation

• Symptoms of right-sided numbness, especially upon waking, should be treated as a neurological emergency due to high suspicion for stroke, which requires immediate medical attention 1
• The Cincinnati Prehospital Stroke Scale should be used for rapid assessment, evaluating facial droop, arm drift, and speech abnormalities 1
• If any of these three signs is abnormal, the probability of stroke is 72% 1
• Fatigue combined with neurological symptoms may indicate a cerebrovascular disorder 2, 3

Immediate Diagnostic Workup

• Brain MRI with diffusion-weighted imaging is the preferred initial imaging modality to detect acute ischemic changes 1
• CT head without contrast can be performed if MRI is not immediately available to rule out hemorrhage 1
• CT angiography or MR angiography should be included to evaluate for carotid and vertebral artery disease 1
• Laboratory tests should include:
  • Complete blood count to assess for infection or polycythemia 1
  • Basic metabolic panel to evaluate electrolyte abnormalities 1
  • Coagulation studies (PT/INR, PTT) to assess stroke risk factors 1
  • Blood glucose measurement (hypoglycemia can mimic stroke symptoms) 1
  • Inflammatory markers (ESR, CRP) to evaluate for inflammatory conditions 1

Extended Diagnostic Considerations

• If initial imaging is negative but symptoms persist, consider:
  • Electroencephalogram (EEG) to rule out seizure activity, especially with transient symptoms 1
  • Lumbar puncture if infectious or inflammatory CNS disease is suspected 1
  • Evaluation for cerebral venous thrombosis with MR venography if patient has risk factors or conventional imaging is negative 1
  • Transcranial Doppler ultrasound to assess for vertebrobasilar insufficiency if symptoms suggest posterior circulation involvement 1

Special Considerations Based on Clinical Context

• If symptoms occurred upon waking, evaluate for:

  • Sleep-related breathing disorders that may cause morning fatigue and transient neurological symptoms 1
  • Positional vertebrobasilar insufficiency that may cause symptoms with certain head positions 1
  • Nocturnal seizures that could present with post-ictal right-sided weakness 1

• If fever is a prominent symptom, consider:

  • Infectious causes of stroke (endocarditis, meningitis) 1
  • Systemic infections with neurological manifestations 1
  • COVID-19 infection, which has been associated with neurological symptoms including stroke 1

Common Pitfalls to Avoid

• Dismissing right-sided numbness as a benign symptom without thorough neurological evaluation 1
• Attributing symptoms solely to fatigue or fever without considering stroke as the primary diagnosis 1
• Delaying imaging studies in patients with transient symptoms, as they may represent TIAs which require urgent evaluation 1
• Failing to maintain adequate oxygenation (should be kept >94%) in patients with suspected stroke 1
• Overlooking non-stroke causes of similar symptoms such as complex migraines, seizures, or multiple sclerosis 1

Remember that time is critical in stroke management, and early recognition with prompt imaging and intervention can significantly improve outcomes and reduce morbidity and mortality 1.