November 2015 Pulmonary Case of the Month

Kristal Choi, MD

Lewis J. Wesselius, MD

Department of Pulmonary Medicine

Mayo Clinic Arizona

Scottsdale, AZ

History of Present Illness

A 66 year-old woman was admitted to neurology with acute-onset dysarthria, right facial droop, and right-sided hemiparesis as a stroke alert. She also had a nonproductive cough and intermittent dyspnea for 4 months.

Past Medical History, Social History and Family History

• She has a history of hypertension and hyperlipidemia. 
• She smoked 1-2 packs/day for 15 years but quit 35 years ago. She drinks two glasses of wine per day.
• There is a family history of bowel and breast cancer.

Physical Examination

• Vital signs: T 36.8, HR 81, BP 129/75, RR 18, O2 sat 93% RA
• General: No acute distress. Awake and alert.
• Heart, abdomen, and lungs: No significant abnormalities
• Neurological: Mild right-sided nasolabial fold flattening.  Evidence of ptosis o the right eyelid. Hemiparesis on the right, the arm greater than leg. Sensation intact. Dysmetria on the right upper and lower extremities.

Laboratory Evaluation

• CBC: Hemoglobin 11.9 g/dL, white blood cells (WBC) 7,900 cells/mcL, platelets 290,000 cells/mcL
• Basic metabolic panel: Na+ 139 mEq/L, K+ 4 mEq/L, Cl- 100 mEq/L , bicarbonate 22 mEq/L, creatinine 0.7 mg/dL

Radiography

A head CT angiogram (CTA) was performed (Figure 1).

Figure 1. Representative images from CTA of the head.

Which of the following should be done next? (Click on the correct answer to proceed to the second of six panels)

1. Administer an intravenous injection of tissue plasminogen activator (TPA)
2. Administer detachable coils (coiling or endovascular embolization) or stereotactic radiosurgery
3. Begin an anti-convulsant and dexamethasone
4. 1 and 3
5. All of the above

Cite as: Choi K, Wesselius LW. November 2015 pulmonary case of the month. Southwest J Pulm Crit Care. 2015;11(5):200-8. doi: http://dx.doi.org/10.13175/swjpcc134-15 PDF