If your patient has Facial Droop, Slurred Speech and Afib so what do you think the most propable cause of his facial weakness is? Bell's Palsy or Stroke? (Remember, Afib can send embolus to the brain causing stroke).
75 yo AAF was admitted to the hospital because his daughter noticed that the patient woke up with a left facial droop and slurred speech.
She called 911 because she suspected a stroke.
On arrival in ER patient's EKG showed a new onset Afib with rate of 75 bpm.
PMH: ESRD on HD, HTN, DM, severe AS with 0.6 cm2 deemed inoperable due to ESRD
CT of the head showed an occipital stroke of unknown age (new since the previous CT 4 years ago), atrophy and ventriculomegaly.
Is it a stroke?
Physical exam was remarkable for left facial drooping and slurred speech (dysarthria).
What is your diagnosis?
Patient was unable to wrinkle his forehead which was indicative of LMN palsy of CN 7 (Bell's palsy).
U MN damage
U pper face is OK (patient is able to wrinkle his forehead)
LMN damage = patient is unable to wrinkle his forehead (our patient)
The exam for CN 7 palsy is remembered by the mnemonic COWS:
C lose your eyes
O pen (Dr. tries to open patient's eyes)
W rinkle your forehead
Don't ask "show me your teeth" because a common reply is "I don't have any teeth!".
The rest of the exam was unremarkable apart from a high pitched 4/6 ESM in the aortic area radiating to the carotids (murmur of the previously known 0.6 cm2 AS).
One important point on the physical exam of an ESRD patient?
What is the HD access? In this patient the access was a LUE AV fistula with a good thrill and pulse.
What to do?
Patient was started on Lovenox (molecular weight heparin ) 1 mg/kg SQ BID for Afib anticoagulation with plans to start Coumadin the next day.
Acyclovir and Prednisone were started for his Bell's palsy.
No evidence of herpetic skin or ear canal lesions was found.
What about the dose of the medications?
Exactly. You cannot just start Lovenox and Acyclovir. You have to adjust the dose for a HD patient.
Lovenox dose was reduced by 50% and it was given QD (1 mg/kg SQ QD). Acyclovir is given BID instead of 5 times per day (q 4 hr).
Patient had a persistent bleeding from the AVF which stopped only after Lovenox was D/C'd.
He was sent home on ASA + Plavix, Acyclovir and Prednisone.
A new technique for AFib treatment is a radiofrequency ablation done at CCF and UH.
What did we learn from this case?
Not all cases with a facial droop and slurred speech are caused by stroke.
Bell's palsy is very common.
Always check if the medication you are prescribing to your patient has to be adjusted for his CrCl.