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A fifty-nine (59) year old black American with hypertension and hypercholesterolemia is brought
to the emergency department. She has a history of tobacco use for 25 year; quit ten years ago.
Husband smoked one pack per day. She has a positive family history of heart disease.
Occasionally takes walks in the neighborhood with friends, but does not have a regular
In the emergency department, Mrs. Johnson is alert and oriented. Her vital signs are
temperature 98.2 F (36.7C), blood pressure 148/97, pulse 81, and respiratory rate 14. An
electrocardiogram (EEG, EKG) monitor shows a normal sinus rhythm. Mrs. Johnson is still
complaining of “numbness” of the right side of her face and down her right arm. Her mouth is
noted to divert to the right side with a slight facial droop when she smiles. Her speech is clear.
She is able to move all of her extremities and follow commands. Her pupils are round, equal,
and reactive to light (4mm to 2 mm) and accommodation. There is no nystagmus noted. Her
right hand grasp is weaker than her left. Mrs. Johnson does not have a headache and denies
any nausea, vomiting, chest pain, diaphoresis, or visual complaints. She is not experiencing
any significant weakness, has a steady gait, and is able to swallow without difficulty.
Laboratory blood test results are as follows: white blood cell count (WBC) 8,000 cells/mm,
hemoglobin (Hgb) 14 G/dL , hematocrit (Hct) 44%, platelets = 294,000 mm, erythrocyte
sedimentation rate (ESR) 15 mm/hr, prothrombin time (PT) 12.9 seconds, international
normalized ratio (INR) 1.10, sodium (Na) 149 mEq/L, Potassium (K) 4.5 mEq/L, glucose 105
mg/dL, calcium (ca) 9.5 mg/dL, blood urea nitrogen (BUN) 15 mg/dL, and creatinine (creat) 0.08
mg/dL. A head computed tomography (CT) scan is done which shows no acute intracranial
change and magnetic resonance imagery (MRI) is within normal limits. Mrs. Johnson is started
on an intravenous heparin drip of 25,000 units in 500cc of D5W at 18 ml per hour (900 units per
hour). Mrs. Johnson is admitted for a neurology evaluation, magnetic resonance angiography
(MRA) of the brain, a fasting serum cholesterol, and blood pressure monitoring. Upon
admission to the nursing unit, her symptoms have resolved. There is no facial asymmetry and
her complaint of numbness has subsided.