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83 y.o. Female who is 5 mos s/p R ACA stroke. Has recovered nicely, but now c/o 2 day Hx of "black clouds" floating in L eye obscuring her vision. This will occur and last several hours and has recurred by her report x2, generally when she gets up at night. She has unknown cholesterols, known HTN that has never been well controlled on several meds and about 3 wks ago stopped taking her CCB; only on HCTZ and Aliskiren, BP still in the 180 systolic range. Nonsmoker.

 

My opinion is that this lady needs emergent/urgent evaluation and that her busy life should take a backseat for a few hours while she gets sorted out. Am I wrong?

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Stat MRI brain is needed but not aggresive bp control on the watershed theory

if neg mr would get bp under control asap and either way have a long discusion on code status and living will

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I agree with a brain scan, she most certainly needs carotid dopplers for possible stenosis and EKG/pulse check to r/o A-fib.

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Ok - thanks. This is actually a personal case. A family member is refusing reasonable care despite calling me and asking what she should do. It's been frustrating and I just needed to vent and validate for a moment.

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Ok - thanks. This is actually a personal case. A family member is refusing reasonable care despite calling me and asking what she should do. It's been frustrating and I just needed to vent and validate for a moment.

 

Sounds like grandma......just saying...

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As mentioned above would also strongly consider MRA head and neck (can be done with or without contrast) or CTA head and neck (would no longer need carotids if neck is done).

 

As an embolus phenomenon to the same vascular territory would be unlikely; an intracranial stenosis is more likely causing the repeat neurological symptoms when her BP drops (ischemia). As you mentioned this occurs when she gets up at night (BP drops).

 

Some neurologists would also consider IV heparin or other AC until vessel imaging was done.

Two years as a stroke PA.

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if all else fails call 911 right after you step in the door of her house - then let her/him sign off on the do not transport

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