Case Study: Gradual Onset Arm Weakness

As often discussed and reported, we learn well from case studies. Today, we’re going to talk about the case study of a 52-year-old female.

About 10 years ago, I was working in a critical access emergency department as a solo provider. This 52-year-old female came in with the chief complaint of right arm and leg weakness with a gradual onset of about six hours. She had a little difficulty walking and she had very focal findings in half of her body.

Her blood pressure was extremely high, 208/120. Two weeks prior, she had seen her doctor and they put her on hydrochlorothiazide. She was to be followed up in two weeks. So, she had very high blood pressure and now she comes in with these neurological findings. She was a younger lady, but this all sounds like a stroke. She has stroke-like symptoms and is outside of any acute therapeutic window like thrombolytics.

It was ER workup to include a head CT (to make sure there was no bleed) and some screening labs, but her blood pressure was also really high. What do you do with a high blood pressure in the setting of a stroke?

You have to understand that when someone has a stroke, part of their brain dies – they have a brain injury. There’s an area of the brain that’s dead, not viable, but there’s also a penumbra, a watershed area around the infarction that’s potentially viable. Our job is to make sure there’s no additional damage; we want to preserve the penumbra.

You do that by making sure the patient is well-oxygenated and that their blood glucose is under control. If you have some who is hyperglycemic, that blood sugar goes into the anoxic penumbra and doesn’t metabolize well. That has been shown to increase damage. Also understand that the body realizes there’s a brain injury, so there will be hyperperfusion and therefore, they’re always hypertensive.

When someone has an acute thromboembolic stroke, you have to be cautious in lowering blood pressure. There are some criteria for using thrombolytics, but I’m not talking about a patient being a thrombolytic candidate. As a PA, I want to talk to somebody before using thrombolytics. I’m not using antihypertensive medication to lower blood pressure until someone tells me to. If someone is hypertensive from a stroke, don’t touch their blood pressure until someone tells you to.

As a hospitalist, I admitted lots of stroke with neurology, and everybody always told me, “Leave the blood pressure there. They need to autoperfuse that area of their brain and dropping the blood pressure could increase harm.”

So, in this particular case, we used antiplatelets on the patient and it didn’t do anything with her blood pressure. I transferred the patient to a bigger stroke facility. Stroke out of the way.

Mnemonic: Days of the Week

I often teach this mnemonic to help you recognize stroke-like symptoms that aren’t a stroke. You can have a stroke any day of the week, so each letter of the week is a stroke-like symptom.

• Monday is a migraine. You could have an atypical ocular migraine look like a stroke.
• Tuesday is Todd’s paralysis. Someone who is postictal from a seizure could have weakness on half of their body.
• Wednesday is Wernicke’s. Wernicke’s encephalopathy is a thiamine deficiency which classically presents with a degree of ataxia and some visual disturbances.
• Thursday is temporal arteritis, which typically presents in an older female but could be anybody with a vasculitis. Temporal arteritis, also known as giant cell arteritis, is a headache on half the head with visual changes. There doesn’t always have to be a headache.
• Friday is functional. They’re playing games, whether it’s someone with a secondary gain or a conversion disorder.
• Saturday could be a systemic infection like syphilis. Tertiary syphilis is really on the rise these days.
• Sunday is sugar. No stroke is a stroke until you check blood sugar.

So, we sent this patient to the stroke facility. Two weeks later she comes back to the ER with a cough and a fever. All of a sudden, her blood pressure is under control. I remember her, and say, “What happened? Tell me about your admission.”

She says, “I was admitted and they said I had a stroke.” “Okay, what else?” She said, “They found one of my kidneys is dead and they’re going to have to do surgery on the kidney. I ask, “What did they say that was from?” She said, “They don’t know. They think it was a childhood trauma.”

I say, “Okay, interesting. What else?” She goes, “I had a thrombus in my neck. They had to do surgery to take out.” So I ask, “What do you mean by that?” She described to me, not a carotid endarterectomy, but a real thrombus in her neck. All I can think is, “That’s really weird.”

A stroke, a blood clot in the neck and a dead kidney.

Now, the patient is in the emergency room again with what looks like pneumonia. She has a cough, a low-grade fever and it hurts when she breaths. I do a workup and she has a little bit of a white count with a fever of 101 or 102. In the right side of her chest they said, “Infiltrate with some atelectasis.” Everything about this makes me think pneumonia.

With every single patient who has chest pain or shortness of breath, I run my primary mnemonics. I did a lot of work in emergency medicine as a solo provider, so I had to come up with safety nets so I wouldn’t get burned. This started when I was a hospitalist covering telemetry and respiratory at night. Then I battle tested these mnemonics over 15 years and thousands of ER patients.

Mnemonic: Who’s Your PAPPA?

The five causes of chest pain are the mnemonic, “Who’s Your PAPPA?”

• Pericarditis
• Acute coronary syndrome
• Pneumothorax
• PE
• Aneurysm, thoracic dissection

Mnemonic: Don’t Make a HORID Mistake

The five causes of pulmonary symptoms are the mnemonic, “HORID.”

• Heart
• Obstruction
• Reactive
• Infection
• Death

I’m looking at this lady asking myself, “Cardiac?” “Obstructive?” “Reactive?” She’s not wheezing, so I don’t think it’s asthma or COPD. “Infectious?” It could be infectious. Could this be a PE? I don’t think that’s likely, but she was just hospitalized.

I asked her, “Did they have you bedridden for a long time?” She goes, “No, they had me walking the next day.” I’m thinking, she was still hospitalized, but it sounds like she had early ambulation, so that mitigates the risk of immobilization. But wait a second, what are the risk factors for DVT/PE?

Mnemonic: Virchow’s Triad or DSH

• Damage: That’s typically a broken bone or some kind of intravascular procedure, which this patient didn’t have.
• Stasis: I’m concerned that she was in the hospital in bed, but she didn’t have any leg findings.
• Hypercoagulable states: She doesn’t have a history of hypercoagulable state.

But, a young lady with a stroke (possibly hypertensive induced) and a dead kidney. A dead kidney can definitely give you a secondary cause of hypertension. Why did the kidney die? It doesn’t sound like they knew at the bigger hospital. And she had a thrombus in her neck.

Could she be hypercoagulable? Is it possible that she has a hypercoagulable state that hasn’t been diagnosed? The more I thought about it, the more I realize it’s probably just pneumonia. But as an advanced practitioner, I want to share this diagnostic fork in the road with my supervising doc. I called my supervising doc and explained the whole picture. The doc told me to call the pulmonologist and run it by them.

I called the pulmonologist and told him, “If you say this is pneumonia, I’ll treat it like pneumonia, no problem.” But I talked to the pulmonologist and he said, “You know, John, I’ve been burned so many times, you better send her down.” I send the patient down because we couldn’t do a CAT scan to rule out PE where I was working.

Late in the afternoon, I got the phone call telling me she was loaded with PE. PE everywhere.

Safety Nets

What are some of the safety nets here? Firstly, there’s a lot of medicine in what I just discussed. I challenge you to think about how comfortable you are with stroke, hypertensive emergencies and the differential diagnosis of a stroke.

Look up the different findings of a pulmonary embolism. What are some of the findings and presentations of a PE? If you look at the PIOPED data, they say 73% of patients have shortness of breath. That means one in four has no shortness of breath.

What’s the second most common complaint? Sixty-six percent of the time, patients complain of pleuritic chest pain. One in three won’t have chest pain. Leg complains are 44% of the time, cough is 37% of the time and 21% are wheezing. PE is sneaky. It could have chest pain or no chest pain. It could have shortness of breath or no shortness of breath.

What are the signs of a PE? Fifty-four percent are breathing fast, tachypneic. About half (47%) have leg findings. Twenty-four percent, one in four, are tachycardic. Eighteen percent have rales. Three percent have a fever.

PE is incredibly sneaky because we think one means the other. This is the main reason thoracic dissections are missed. We see a lot of abdominal aneurysms, and as soon as that aneurysm bursts, the patient is writhing in pain and you think that equates to a thoracic dissection. Thoracic dissections will dissect, and the patient has a lot of pain then, but once a dissection goes through the intima, the pain goes down. They have a very different pain pattern.

Same thing with PE. You have two different kinds of PE, big ones and small ones. A big PE hits you right in the central circulation, knocks you on your keister and drastically affects your vital signs. You look sick, so no one misses those. Yes, they’re going to be tachycardic; yes, they’re going to be hypoxic; yes, they’re going to look like absolute crap and have shortness of breath. But there’s no chest pain. What do you mean, no chest pain? The lung has no nerve tissue in it, so there’s shortness of breath but no pain.

It’s the small PEs that go peripheral. They’re the ones with no shortness of breath. There’s only a small percent of their pulmonary cardiovascular function in jeopardy. Therefore, they don’t have tachycardia or tachypnea. But when they take a deep breath it hurts, because the inflamed area of the lung touches the pleura, which is a hotbed of nerves. Pleuritic chest pain is a really big finding.