Case 12

Gladys Forsythe
October 22, 2009
Problem List
Date of Onset
October 22, 2009
September 10,

Date recorded
October 22, 2009
October 22, 2009

Active
1) L MCA stroke
2) TIA

2009
2006

October 22, 2009

3) Chronic HTN

Unknown
Unknown
Unknown
Date of Onset
1959-1978

October 22, 2009

October 22, 2009
October 22, 2009
Date recorded
October 22, 2009

a. LVH
4) Degenerative joint disease
5) Alcohol: 1-2 cocktails most evenings
6) Family H/O breast cancer (mother)
Inactive
7) 19 pack year H/O smoking

Assessment and Plans

#1 L MCA stroke
Assessment: Aphasia, right face and right arm paralysis and sensory loss are all suggestive
of L MCA stroke, due to a history of TIAs and metabolic syndrome. No history of surgery or
trauma. She is not eligible for tPA due to acute hyperglycemia (> 150mg/dL), which studies
show is an independent risk factor for failure of recanalization with tPA treatment, and
increased risk for symptomatic intracerebral hemorrhage. The exact time of stroke is
unknown. Her husband verifies that she was normal when she went to bed at 11pm. The
recommended timeframe for tPA treatment is the onset of ischemic stroke symptoms < 4.5
hours before beginning treatment.
Goal: Maximal diagnostic and therapeutic effort including invasive procedures as needed.
Plan
Dx
R/O ischemic stroke head CT w/o contrast, carotid duplex dopplers
R/O hemorrhagic stroke, TIA, brain tumor head CT w/o contrast
R/O hypertensive encephalopathy HPI, head CT w/o contrast
R/O psychological disorders psychological evaluation
Rx
NPO, insert NG tube, administer Aggrenox (25mg Aspirin + 200mg Extended-release
dipyridamole capsule) BID ASAP. Continue Aggrenox throughout endarterectomies
indefinitely in the absence of contraindications.
Subcutaneous enoxaparin 40mg QD for 1 week.
Physical therapy/speech therapy. Stroke support group.
Wait 4-6 weeks to perform a left endarterectomy.
#2 Chronic HTN
Assessment: Optic fundoscopy findings of a 3/1 A/V ratio with AV nicking, and LVH all
suggest chronic HTN, which is an early sign of end-organ damage that needs to be
addressed to prevent impending cardiovascular risks.

Case 12
Gladys Forsythe
October 22, 2009
Goal: For patients who have had a stroke or TIA in the setting of severe large artery stenosis,
cautiously lower BP as tolerated without a specific BP goal.
Plan
Dx
R/O chronic HTN HPI, echocardiography, EKG
Rx
Losartan 50mg QD orally
#3 Dyslipidemia
Assessment: Patients stroke history and metabolic syndrome classifies her as a coronary
heart disease risk equivalent. Aggressive treatment is needed.
Goal: Target LDL level of < 70mg/dL to obtain maximum benefit.
Plan
Dx
R/O dyslipidemia - lipid panel, carotid duplex dopplers
Rx
atorvastatin 80mg QD orally
Pt Ed
Emphasize the importance of challenging herself to use her muscles as often as she can to
regain maximum function.
Aggressive lifestyle modifications to control her metabolic syndrome and prevent further
complications: Regular aerobic physical activity, salt restriction, limited alcohol consumption,
and a Mediterranean diet (rich in fruits, vegetables, olive oil, whole grains, low-fat dairy
products).
Follow/up
Mrs. Forsythe will return to the hospital in 2 week to monitor her progress, or go to the ED
immediately if symptoms reoccur. Plans for a left endarterectomy will be discussed.