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Stroke Code*

History of Present Illness:

A woman in her late 70’s is brought to the ER by medics for facial droop, slurred speech and left sided weakness.  She lives at a nursing home and at baseline is bedridden but A+Ox4 and able to feed herself.  She was last seen normal about 1.5 hours prior to ER arrival.  Her PMH includes CVA, HTN, DM, CAD, CHF, A-fib and GERD.  She is hard to understand due to her slurring but does complain of headache and left sided weakness.  She verbalizes no other complaints.

Vital Signs & Physical Exam:

Vital signs are normal except for BP 171/89.  Physical exam is notable for weakness in all extremities but she is able to lift her right arm and leg off the bed but not the left side, though she can move it a little.  Speech is slurred to the point of being difficult to understand with left facial droop.  Heart is regular and lungs are clear.  Her skin is dry.  A stroke code order set is entered.

What is the most important question to ask the medics?

  • A) Is she on blood thinners?
  • B) What is the last known well time?
  • C) What is the finger-stick?
  • D) What is the code status?

SCROLL DOWN FOR ANSWERS & 1-MINUTE CONSULT

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ANSWER:

  • A) Is she on blood thinners? Good question, but not critical as you are going to go through her med list and call the SNF
  • B) What is the last known well time? Critical to know, but the medics usually are not the best source for this information.  I always assume they are wrong and ask probing questions of the patient or others that she lives to get a more accurate estimate of last known well time.
  • C) What is the finger-stick? CORRECT.  You need this info ASAP and the medics are likely the only ones who have it.  She has DM and they didn’t report this.  If they didn’t check, you should before you send her to CT or you get the results of the chem 7 from the lab.
  • D) What is the code status? Important to know, but you are going to get this from the papers the SNF typically send or from the patient or family.

1-Minute EM Consult on the topic for this case from the Emergency Medicine 1-minute Consult Pocketbook

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CASE CONCLUSION: glucose was 33.  Symptoms improved after treatment of hypoglycemia.  Stroke code was cancelled and regular CT was done which showed no bleed.

CASE LESSONS: Ask medics what the glucose was.  If they don’t know, check it stat in anyone with symptoms that could be due to hypoglycemia

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