Can you provide practice exercises or simulations to test my understanding of stroke diagnosis and management in a 65-year-old man with hypertension (high blood pressure) and diabetes, presenting with sudden onset of right-sided weakness and difficulty speaking?

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Stroke Diagnosis and Management Practice Simulation

I'll present you with clinical scenarios involving acute stroke presentations. After each case, I'll ask you specific questions about diagnosis, localization, and management. Answer each question, and I'll provide feedback on your clinical reasoning.

Case 1: The Classic Presentation

Scenario: A 68-year-old woman with hypertension (on lisinopril) and type 2 diabetes (on metformin) is brought to the ED by her daughter. The daughter states that 90 minutes ago, her mother suddenly couldn't lift her right arm and her speech became slurred. The patient is alert but frustrated because she can't express herself clearly.

Vital signs: BP 178/96 mmHg, HR 82 bpm regular, RR 16, O2 sat 98% on room air, glucose 156 mg/dL

Physical exam: Right arm drift with 2/5 strength, right leg 4/5 strength, right facial droop, expressive aphasia (patient understands commands but cannot speak fluently)

Questions for you:

  1. What specific vascular territory is affected based on the pattern of deficits?

  2. What is the SINGLE most critical piece of information you need to establish immediately, and why?

  3. List the imaging studies you would order, in priority sequence, and state what specific question each one answers.

  4. The patient's blood pressure is 178/96 mmHg. Should you treat it now? If yes, what is your target? If no, why not?

  5. Assuming the patient meets all other criteria, what is the time window for IV tPA administration, and what is the approximate risk of symptomatic intracerebral hemorrhage?

Case 2: The Diagnostic Challenge

Scenario: A 72-year-old man with a history of hypertension, diabetes, and a stroke 2 years ago (with full recovery) presents to your clinic complaining of dizziness and "feeling weak" that started yesterday morning. He describes the dizziness as "the room spinning" and says his left leg feels "heavy."

Vital signs: BP 168/92 mmHg, HR 76 bpm regular, glucose 188 mg/dL

Physical exam: Vertical nystagmus, left leg weakness 4/5, mild left arm weakness 4+/5, ataxic gait

Questions for you:

  1. Based on the combination of vertigo and weakness, what vascular territory should you be most concerned about?

  2. What is this patient's stroke risk category, and what is the timeframe for completing brain imaging?

  3. The patient asks if he can go home and see his regular doctor next week. What do you tell him and why?

  4. What specific physical examination maneuver is MORE sensitive than early MRI for detecting stroke in patients with cerebellar symptoms?

Case 3: The Time-Critical Decision

Scenario: A 65-year-old man with hypertension and diabetes is brought to the ED at 3:00 AM. His wife found him on the floor of the bathroom at 2:30 AM with right-sided weakness and difficulty speaking. She states he went to bed at 10:00 PM and was normal at that time. She woke up at 2:30 AM and found him like this.

Vital signs: BP 192/104 mmHg, HR 88 bpm irregular, glucose 178 mg/dL

Physical exam: Right hemiparesis (arm 1/5, leg 2/5), global aphasia, right facial droop, NIHSS score 16

Non-contrast CT head (completed at 2:50 AM): No hemorrhage, no early ischemic changes

Questions for you:

  1. What is the "last known well" time for this patient?

  2. Is this patient eligible for IV tPA based on the time window? Explain your reasoning.

  3. The patient's BP is 192/104 mmHg. What should you do about it before considering tPA?

  4. What additional imaging study should you obtain, and should you wait for its results before giving tPA?

  5. The irregular heart rate suggests atrial fibrillation. When should you start anticoagulation if this is confirmed?

Case 4: The Atypical Presentation

Scenario: A 58-year-old woman presents to the ED with sudden onset of severe headache that started 2 hours ago while she was exercising. She describes it as "the worst headache of my life." She also reports some neck stiffness and photophobia. No focal weakness.

Vital signs: BP 164/88 mmHg, HR 92 bpm, temp 37.2°C

Physical exam: Alert, oriented, no focal neurological deficits, mild nuchal rigidity, photophobia

Non-contrast CT head: No hemorrhage visible

Questions for you:

  1. What diagnosis must you consider despite the negative CT, and what is your next diagnostic step?

  2. If you were considering ischemic stroke instead, would the negative CT exclude it? Why or why not?

Please answer these questions, and I'll provide detailed feedback on your clinical reasoning, highlighting what you got right and where your understanding needs refinement. Focus on being specific rather than general in your answers.

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Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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