EM Forum Case #117 "The Silent
Senior"
by Charlene Babcock Irvin, MD, FACEP
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A 75 y/o female presents after falling while
on the way to the bathroom. She is brought
by EMS and noted to have a dense hemiparesis
on the right. Family noted she had gotten
out of bed to go to the bathroom when she
fell. They heard the ‘thump’ and when they
got there, they noted she wouldn’t talk. She
also could not walk, so they called EMS.
PMH: Per family: hypertension and
keloids.
Per
family, patient was fine when she went to
bed < 1 hour earlier.
PE: 97F, P=91,
RR=18, BP=114/72, Sat=97%. In general, she
appears mute and obtunded. She will follow
some simple commands.
HEENT: Eyes
deviated to Left, PERRL, and neck supple.
Heart: Irregular rhythm
Lungs:
Clear bilaterally
Abd: Soft,
non-tender
Ext: Unremarkable
Neurologic: Difficult exam - Generally
obtunded, unable to speak, can follow some
simple commands (such as open and close
eyes), Forced deviation of eyes, minor
facial paralysis, unable to move right arm,
and left arm weak. The right leg is weak as
well.
NIHSS score = 22
Questions:
1. What
is the maximum NIHSS score?
2. Is
this patient a candidate for Intravenous
TPA? What score is too low? Too high for
treatment?
3. What is the time cutoff
for intravenous TPA?
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