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Confusion & Shaking

UnFiNiShEd CaSe CoMe BaCk LaTeR

History:

An otherwise healthy 32-year-old female presents to the ED for sudden shortness of breath and evidently confusion with shaking.  She was recently diagnosed with migraines due to recurrent left-sided headache.

Exam:

Vital signs are normal .   Exam is normal.

Initial differential diagnosis:

  • Anxiety
  • Migraine
  • Seizure
  • Drugs
  • Stroke

Relevant Test Results:

  • EKG: none
  • Labs: none ordered
  • Imaging: none

QUESTIONS:

  1. What does the case image show?  
  2. What should you do next?  
  3. Want a 1-minute consult/tutorial on this case? 
  4. Want to know what happened with this patient?

SCROLL DOWN FOR ANSWERS & 1-MINUTE CONSULT

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ANSWERS:

  1. What does the case image show?  The image shows basal ganglia mass v. CVA on the left (side of her “migraine”).  MRI shown below with reading
  2. What should you do next?  Give aspirin, consult neurology and do a workup to find out why she has a stroke.  Consider PFO, hypercoaguable state and dissection among other conditions
  3. Want a 1-minute consult/tutorial on this case?  See yellow area from sample page below.
  4. Want to know what happened with this patient?  See case conclusion below tutorial page.

1. Subacute left basal ganglia infarct.
2. Multiple small left MCA territory cortical infarcts.
3. Likely small chronic right cerebellar infarct.

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

CLICK HERE TO LEAR MORE ABOUT THIS BOOK

CASE CONCLUSION: Admitted for stroke.  Had a positive hypercoaguable work-up and was started on Eliquis.

CASE LESSONS:

  1. Young people do get strokes
  2. Posterior circulation stokes may present in odd ways.  Headache is common and often mimics migraine.  Involuntary movement can mimic a seizure.
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