CHIEF COMPLAINT:  New onset dysarthria and left hemiparesis


J.S. is a 52-year-old obese Caucasian male with an extensive past medical history including morbid obesity and prostate cancer treated with external beam radiation and hormonal therapy in 2014 and is now NED (no evidence of disease).  He also carries a history of hypertension, hyperlipidemia, transient ischemic attack (2016), migraine headaches, type II diabetes mellitus, stage II chronic kidney disease, obstructive sleep apnea and coronary artery disease managed medically.  He is generally poorly compliant with seeing his primary care provider and doctors in general.  He tries his best to take his prescribed medications but admits to missing doses several times a week.

However, over the past few months he’s noticed intermittent “fits” of palpitations with dyspnea which he describes as “feeling like my heart is racing.”  He cannot identify precipitating or ameliorating factors and has no prior history of tachydysrhythmias. He says they are associated both with rest and with exertion, typically last between a few seconds to several minutes and are self-terminating.  These episodes have become more and more frequent over the past few weeks. 

He now presents to the emergency department this morning at 7 a.m. with complaints of acute dysarthria and left hemiparesis which extends to the entire left upper and left lower extremity.  He is last known to be well last night when he went to bed with his wife at 10 p.m.   When he awoke today, he was unable to speak clearly, his words were “garbled” and his wife noticed the left sided weakness so she called 911.


Morbid obesity (BMI 39), transient ischemic attack in 2016, prostate cancer diagnosed in 2013 for which he was treated with external beam radiation and hormonal therapy.  He has been deemed NED since 2014 and his most recent PET/CT in 2019 was unremarkable.  Additional medical history includes poorly controlled stage II hypertension, hyperlipidemia, stage II CKD, insulin-dependent type II diabetes mellitus, obstructive sleep apnea (noncompliant with CPAP) and medically stable coronary artery disease.  He denies any past surgical history.


Transient ischemic attack diagnosed in 2016 at which time he presented with dizziness, garbled speech and gait ataxia.  Non-contrast CT scan of the brain was negative for acute CVA.  His symptoms resolved within 16 hours and he was discharged home.  Migraine headaches diagnosed in 2004.  He was prescribed tricyclic antidepressants (nortriptyline) but he stopped taking them due to adverse drug reaction (anticholinergic effects).  He was offered Botox but declined.  He was offered SNRI (duloxetine) but he declined.  He’s currently not on any medical therapy but he’s not compliant with lifestyle modification for his migraine headaches.


  • Mother:  Type II diabetes mellitus, hypertension, paroxysmal atrial fibrillation, coronary artery disease, CHF, TIA/CVA, prothrombin gene mutation, MTHFR x1 copy, PAI polymorphism
  • Father: Prostate cancer, squamous cell carcinoma of the skin, hypertension, hyperlipidemia, type II diabetes
  • Maternal grandfather:  Hypertension, hyperlipidemia, stroke
  • Paternal grandfather:  Pancreatic cancer
  • Maternal grandmother:  Anxiety disorder, major depression, hypertension
  • Paternal grandmother:  Rheumatoid arthritis


  • Lives at home with wife and mentally disabled adult son
  • Smokes 1 pack per day of cigarettes since age 17.  No attempts at quitting.
  • Drinks 6 to 8 beers per night since age 22.
  • Denies illicit drug use.
  • Occasionally sexually active with spouse


  • Annual wellness exam 2019
  • Digital rectal/prostate exam 2019 unremarkable
  • Refused colonoscopy at age 50
  • Cologuard at age 51 unremarkable
  • Does not recall last visit to ophthalmologist or podiatrist for DM


  • Primary care provider
  • Neurologist
  • Neuro-interventional radiologist
  • Cardiologist


  • Reportedly up-to-date with age appropriate vaccines.


  • Metoprolol succinate 100 mg tablets, 1 tablet po daily
  • Amlodipine 10 mg po daily
  • Rosuvastatin 20 mg po nightly
  • Multivitamin with B-complex, 1 tablet po daily
  • Lisinopril 20 mg po twice daily
  • Metformin XR 500 mg tablets, take 4 po nightly
  • Lantus 62 units SQ nightly
  • Victoza 1.8 mg SC daily
  • Aspirin 81 mg tablet, take 1 tablet QD


  • Penicillin (rash with hives)
  • No known food allergies. 
  • No environmental allergies.


  • T:  98.2
  • RR:  18 bpm
  • HR:  140 bpm
  • BP:  100/60
  • Pain scale:  2


  • Height:  5’9”
  • Weight: 240 lbs
  • BMI:  39


Negative except as noted.


GENERAL:  Morbidly obese white male in no acute distress

HEENT:  Left pupil 4 mm.  Right pupil 2 mm.  Pupils reactive briskly to light.  EOMI.  No nystagmus.  Oropharynx clear.  No facial crepitus or tenderness.  Vision and hearing grossly intact.

Cardiovascular:  Irregularly irregular rate and rhythm, II/VI SEM, no rub or gallop, no peripheral edema.  + 1 thready radial pulses with prolonged capillary refill time.  + Atrial fibrillation with RVR (rate 120s to 140s) on telemetry.

Pulmonary:  Breath sounds are clear to auscultation bilaterally.  Normal work of breathing on room air.

Gastrointestinal:  Abdomen is soft, nontender, nondistended.  No HSM.  Bowel sounds appreciated in all quadrants.

Genitourinary:  No blood at the meatus.  No hematuria.

Musculoskeletal:  Normal spinal alignment.  No midline spinal tenderness or paraspinal spasm. 

Neurological:  Awake, alert and oriented x4.  Face is asymmetrical with right sided facial droop.  Tongue is midline.  Cranial nerves otherwise grossly intact. Speech is garbled and nonsensical.  Moves all extremities spontaneously and can resist gravity.  Gait is unsteady and ataxic.  Motor strength: 3/5 LUE, 3/5 LLE, 5/5 RUE, 5/5 RLE.  Sensory function:  diminished sensation overlying dorsum of LLE.  Unable to discriminate between dull and sharp pin prick.  Diminished deep tendon reflexes LLE (patellar).

Psychiatric: Calm and cooperative.


  • CTA head and neck with perfusion consistent with acute right MCA stroke
  • MRI brain without gadolinium consistent with right MCA stroke
  • 12-lead-ECG revealed AF with RVR (atrial fibrillation with rapid ventricular response) at a rate of 142 bpm. No ST-T changes.
  • CBC revealed microcytic hypochronic anemia with Hgb 10.9 g/dL but otherwise was unremarkable
  • CMP revealed serum creatinine 1.5 mg/dL, BUN 30, glucose 262, K 2.9, Mg 1.5, ALT 48, AST 68,.  Remainder of CMP unremarkable.
  • Lipid panel:  total cholesterol 269, HDL 32, LDL 185
  • Hgb A1c 9.6%
  • Vitamin B12 level 230
  • Lyme, HGA and babesiosis negative
  • ESR and CRP are WNL


Mini Mental Status Exam:  Awake, alert and oriented to person, place, time and situation.

Long term memory is intact:  able to recall events from several years ago.

Short term memory:  unable to recall three objects from 5 minutes ago

CN I:  deferred
CN II:  Pupils:  OD 2mm, OS 4 mm.  Pupils briskly reactive to light.  Visual acuity grossly intact, fundoscopic exam deferred
CN III, IV, VI:  intact without nystagmus
CN VII:  + right sided facial droop.  Tongue midline.  Eyebrow and cheek puff deferred
CN VIII:  Hearing grossly intact; Weber and Rhinne deferred
CN IX, X, XI, XII:  grossly intact

Sensory:  Sensation of superficial touch intact but unable to discriminate between dull and sharp pin prick in the LUE/LLE.  Perception of vibratory sense intact.  Perception of sharp and dull sensation intact in RUE/RLE.  

Deep tendon reflexes:  2+ DTR in bicep, and achilles tendons bilaterally. 1+ DTR in left patella.  2+ DTR right patella.

Romberg test:  Negative.

Posture:  Erect.

Gait:  Steady however ataxia noted during tandem walk.

Tremor:  No tremor of intention appreciated.

Single leg balance test:  Deferred

Muscle strength:  3/5 LLE.  5/5 RUE, 3/5 LUE, 5/5 RLE.


Directions:  Double-spaced paragraphs utilizing APA format (6th ed.).  Must include in-text citations from peer-reviewed sources and texts.  May not use websites as sources unless they are professional e-journals.  Case study must be a minimum of 6 pages and a maximum of 10 pages (not including cover sheet, title page and reference page).

  1. Summarize the presenting case.  Must include a 1 to 2-page succinct synopsis of the case including the chief complaint (CC), the history of present illness (HPI), comprehensive review of systems (ROS), comprehensive physical exam (PE), diagnostics and relevant information.

  2. Must include a comprehensive ROS and PE.  Must write out a thorough systems-based ROS and PE.  For symptoms and objective findings that are not explicitly listed in the case information, you may write normal findings.  Must use medical terminology.  Utilization of lay-terminology will result in grade point deductions.

    For example, the CV review of systems and PE could be something like: “Cardiovascular:  Denies chest pain, palpitations, dyspnea on exertion or lower extremity edema.”

    “Cardiovascular:  Regular rate and rhythm, S1S2, no murmur, rub or gallop, no extra heart sounds, no JVD, no peripheral edema, radial pulses 2+ palp”

  3. Comprehensive responses to questions 1 through 4 including relevant in-text citations from peer-reviewed sources.  Comprehensive, thoughtful, articulate personal reflection on the overall case, a critical component of the case, compelling findings and your overall interpretation of the case.

Question #1:

  • What is your clinical impression of J.S.?  Summarize the clinical findings succinctly, explore the case broadly, explore the chief complaint and how it relates to the diagnosis or acute MCA cerebrovascular accident and new onset atrial fibrillation.  Must use in-text citations to support your findings.

Question #2:

  • What diagnostic studies, tools, tests and criteria are utilized in the work up and diagnosis of CVA?  Thoroughly investigate and explain etiologies for stroke including the most likely cause of this patient’s CVA.  Could this stroke have been prevented?

Question #3:

  • What are the different subtypes of stroke?  Explain the similarities and differences between these subtypes.  What is the difference between TIA and CVA?  What is the most likely etiology of J.S.’s stroke and what evidence do you have to support your diagnosis?  What is the evidence-based-treatment modality for this condition?  Use in-text citations to support your discussion.

Question #4:

  • Stroke may present in a similar fashion as several other neurological conditions.  Name four relevant differential diagnoses.  Explain and defend your rationale including why these diagnoses could fit the clinical picture, and why these diagnoses are important to consider (and to rule out).  Do not provide obscure diagnoses.  Thoroughly explain commonalities and differences between acute CVA (in particular, J.S.’s specific subtype of CVA) with your differential diagnoses.  What diagnostic studies could you employ to help distinguish one diagnosis from another?  Use in-text citations to support your discussion.

Question #5:

  • During your evaluation of J.S., what did you find informative, compelling or made you think differently about the case?  Have you ever treated a patient like J.S. and if not, how would you approach a similar patient who presented with such a varied constellation of signs and symptoms as she did?  Lastly, how do you feel about this case personally as a student nurse practitioner and how can her case impact your clinical practice going forward?

MC, 2020



Student Name: 



RatingExcellent (15-20 pts)Good (8-10 pts)Inferior (2-5 pts)
A.  Succinct summary of the presenting case.

One-page synopsis of the Chief Complaint (CC), History of Present Illness (HPI), Review of Systems (ROS), Physical Exam (PE) findings
Demonstrates complete synopsis of the case findings.    Demonstrates some but limited areas or missing details surrounding case findings.Inadequately defines case findings.
B. Well-articulated reflective responses to questions #1, #2, #3 and #4.

Include peer-reviewed in text citations.

Maximum of 3 paragraphs per response.
Responses convey vigor as reflected in documentation of rationales in a succinct, well thought out and meaningful discussion.Responses reflect poor discussion, or simple transcription of source information.Incorrect responses.

Incorrect diagnoses or missing rationales.

Inferior written reflection.
C. Well-articulated response to question #5.

Incorporates compelling findings that may present complications in this patient’s case.  Must include rationales and in-text citation.

(Maximum of 3 paragraphs)
Responses convey vigor as reflected in documentation of rationales in a succinct, well thought out and meaningful discussion.Responses are made but reflect poor discussion, or simple transcription of source information.Response does not reflect a compelling finding as noted.
D. Use of In-text Citations and external research   Paper must be well researched and resourced.  Must include a reference page with citations per APA formatConsistent appropriate use of in-text citations used and choice references to support discussion.  Inconsistent use of in-text citations used/lacks adequate external research.

Lack of choice references to support discussion.
Lack of substantiated references.   Lack of choice references to support discussion.
Use of no less than 6 current peer-reviewed specialty-related journals (not less than 3 years from present date). 

Includes 6 or more choice peer-reviewed sources.Includes Less than 6 peer-reviewed sources.Does not include choice peer-reviewed sources.

Uses APA format 6th edition.
  Includes the following: 
1. Title page
  2. Reference page   3. Appropriate pagination   4.  Double spacing.  Free of syntax errors and/or typos.
Contains all requisite elements and they are utilized appropriately.Contains some of the requisite elements but is incomplete.Does not contain the requisite elements.  Has more than 5 syntax errors, typos, missing elements.

Final Grade


  • Must use APA format, 6th edition
  • Paper must be double-spaced
  • Must contain title page, running head, pagination, in-text citations and a reference page
  • Must contain at least 6 sources incuding Butarro.  Additional sources must be relevant, recent (within 3 years) and from peer reviewed sources.  No websites are permitted.
  • Must proof read your paper.  Typos, syntax errors, choppy papers will be discredited.
  • 5-point reduction per missing/incomplete/incorrect component
  • Paper must be submitted by the outlined deadline.  No late submissions will be accepted.  All submissions are final.  There are no revisions allowed after it has been submitted and the grades will stand.
  • This is an INDIVIDUAL assignment.  You may NOT work in groups.  Any evidence of plagiarism/collaboration will result in a ZERO
  • Any papers submitted after the deadline will result in ZERO


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