NO OUTSIDE SOURCES ALLOWED! Noticing minor dizziness and slight tingling in his

NO OUTSIDE SOURCES ALLOWED!
Noticing minor dizziness and slight tingling in his left hand at 8 AM, both of which resolved soon thereafter. He assumed these were symptoms due to low blood pressure and therefore opted not to take his blood pressure medications this morning.
PMH
HTN, diagnosed 10 years ago Dyslipidemia
FH
Both parents alive, relatively healthy. Sister, age 62, also has HTN. Son, age 31, has type 1 DM.
SH Married, lives with wife and three children. Occasional recreational beer or wine consumption. Denies tobacco use.
Meds
Amlodipine 2.5 mg PO daily
Simvastatin 10 mg PO daily
Chlorthalidone 25 mg PO daily
Allergy Shellfish (hives)
ROS Mild blurry vision, but no double vision, loss of vision, or oscillopsia
Physical Examination
General: Slender Caucasian man lying in bed in no acute distress, responsive with occasionally slurred speech
VS
BP 192/98, P 70, RR 19, T 98.6°F, O2 sat 97% on RA; Wt 80 kg, Ht 6′0″ Skin Warm, dry
HEENT
PERRLA, EOMI; no nystagmus, exudates, hemorrhages, or papilledema; mild left-sided facial droop. Normal hearing acuity bilaterally.
Neck (–) Carotid bruits, (–) lymphadenopathy Chest
Lungs clear to auscultation bilaterally
CV RRR, S1 and S2 normal, no S3 or S4
Abd Soft, nontender, nondistended, (+) BS
GU Deferred
MS/Ext RUE: 5/5; RLE 4/5; LUE: 2/5; LLE: 3/5. No abnormal or involuntary movements. Strong peripheral pulses and brisk capillary refill; no CCE; DTR: 2+ throughout, normal Babinski reflex.
Neuro Awake, A&O × 3. No aphasia, agnosia, or apraxia. Attention, concentration, and vocabulary are all excellent. No impairment of facial sensation noted with light touch bilaterally. Moderate left facial weakness, as noted by the presence of left-sided facial droop. Mild dysarthria. Shoulder shrug is symmetrical, and tongue is midline on protrusion. Can easily touch chin to chest, and there are no other signs of meningismus.
Labs
Head CT scan: right-sided middle cerebral artery infarct; no evidence of hemorrhage
Carotid Dopplers: normal blood flow bilaterally, no appreciable ischemia or stenosis
Angiogram: not performed
Echocardiogram: no evidence of LV thrombus, ejection fraction 55–60%; overall unremarkable EKG: normal sinus rhythm
ECG showing normal sinus rhythm.
Assessment Acute ischemic stroke secondary to atherosclerosis and ischemic disease in a patient with HTN, dyslipidemia, and no prior history of stroke or transient ischemic attack
CLINICAL COURSE It is now 11:00 AM, and you are seeing the patient with the rest of the neurology team.
CLINICAL PEARL
Initially elevated blood pressures often decrease, without the use of antihypertensive therapy, within the first few days after an ischemic stroke. When initiating antihypertensive therapy after an acute ischemic stroke, caution should be used to not reduce blood pressures too aggressively unless clinically indicated. This approach to blood pressure management in the acute stroke setting is referred to as “permissive hypertension.”
QUESTIONS
Collect Information
1.a. What subjective and objective information indicates the presence of an acute ischemic stroke?
1.b. What additional information is needed to fully assess this patient and to determine a treatment approach?
Assess the Information
2.a. Assess the severity of this patient’s stroke, using the National Institute of Health Stroke Severity Scale, based on the subjective and objective information available.
2.b. Create a list of the patient’s drug therapy problems and prioritize them. Include assessment of medication appropriateness, effectiveness, safety, and patient adherence.
Develop a Care Plan
3.a. What are the goals of pharmacotherapy in this case?
3.b. What nondrug therapies might be useful for this patient? 3.c. What feasible pharmacotherapeutic alternatives are available for the treatment of acute ischemic stroke?
3.d. Create an individualized, patient-centered, team-based care plan to optimize medication therapy for this patient’s acute stroke and other drug therapy problems. Include specific drugs, dosage forms, doses, schedules, and durations of therapy.
Implement the Care Plan
4.a. What information should be provided to the patient to enhance compliance, ensure successful therapy, and minimize adverse effects?
4.b. Describe how care should be coordinated with other healthcare providers. Follow-up: Monitor and Evaluate
5.a. What clinical and laboratory parameters are necessary to evaluate the therapy for achievement of the desired therapeutic outcome(s) and to detect or prevent adverse effects?
5.b. Develop a plan for follow-up that includes appropriate time frames to assess progress toward achievement of the goals of therapy.
SELF-STUDY ASSIGNMENTS
Explain which patients are candidates to receive aspirin instead of warfarin or direct oral anticoagulants for the prevention of stroke in the setting of atrial fibrillation.
2. Read the CHANCE trial and explain when, and for how long, treatment with combination aspirin and clopidogrel is indicated post-stroke or transient ischemic attack.
3. Write a one-page report summarizing the findings of clinical trials utilizing tenecteplase for the treatment of acute ischemic stroke.
Pharmacotherapy Casebook: A Patient-Focused Approach, Eleventh Edition 11th Edition by Terry L. Schwinghammer; Julia M. Koehler; Jill S. Borchert; Douglas Slain; Sharon K. Park and Publisher McGraw-Hill Education /