17 © Springer International Publishing AG 2018 L. Ganti, J.N. Goldstein (eds.), Neurologic Emergencies, https://doi.org/10.1007/978-3-319-64523-0_2 Rule Out Acute Stroke Aunali S. Khaku and Sayed K. Ali Case Presentation A 70-year-old retired male with a history of hypertension, hyperlipidemia, and type II diabetes mellitus presented to the emergency department (ED) at the insistence of his wife. His wife had noticed that “he was not talking right.” In addition, he had spilt his coffee that morning, acting clumsier than normal. On further questioning, he endorsed diffculty getting words out and that his right hand seemed weaker than usual. The symptoms started abruptly at breakfast, waxing and waning for the last 2 h. He denied any pain, fever, or chills. His medications included lisinopril, metformin, and simvas- tatin. He denied current tobacco use (quit about 10 years ago) and drank a few beers socially on the weekends. He had a brother who had a brain tumor. He denied aller- gies, recent surgical procedures, or using any over-the-counter medications. His vital signs on presentation were normal except for a blood pressure of 160/70 mm Hg. He was alert and oriented but had diffculty naming objects and repeating phrases and had a paucity of words (nonfuent). His smile was asymmetric, with a subtle right lower facial droop. Strength testing bilaterally appeared grossly normal, but he had a subtle right pronator drift. Visual feld testing suggested a right upper quadrant visual defcit. NIH Stroke Scale (NIHSS) was calculated as a 6. A non-contrast computed tomography (CT) scan of the head did not show any major abnormalities or bleeds. The patient had no contraindications for intravenous (IV) recombinant tissue plas- minogen activator (rtPA), and after an informed consent was obtained, rtPA was A.S. Khaku, M.D. (*) University of Central Florida College of Medicine (UCF), Orlando, FL, USA e-mail: aunalikhaku@gmail.com S.K. Ali, M.D. Aga Khan University Hospital, Nairobi, Kenya University of Central Florida, College of Medicine, Orlando, FL, USA e-mail: Sayed.Ali@va.gov 2