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The anxious arrival of Eric: a case study

Janet Webb
BSc(Hons) RGN DipN(Lond)
Practice Nurse
Lindum Medical Practice
Lincoln

Eric arrived at the surgery late one morning. The doctors were out on house calls and I was the only clinician on the premises. The receptionist telephoned to say an elderly man with very slurred speech was at the desk and seemed unwilling to leave without being seen. Eric's computer notes told me that he seldom attended the surgery except for the annual flu vaccination. He had no significant medical history, took no regular prescription medicines, and there was no record of family history. Twelve years earlier, someone had recorded a normal blood pressure and that he did not smoke but drank between 1 and 7 units of alcohol weekly.
I called Eric in. He was a tall, thin man, slightly bowed and anxious looking. He took a few seconds to put his shopping down, then sat down and made direct eye contact, which he maintained steadily. I asked how I could help. His speech was, as the receptionist had said, very slurred. He spoke slowly and deliberately, careful annunciating every syllable, and had an obvious left-sided facial weakness. He explained that he had gone to the supermarket to do his shopping, but found when he got to the cash till that he could not speak properly. He had also found it difficult to swallow his saliva. I asked whether the facial weakness had started at the same time, at which he replied that he was not aware of having any facial weakness. His anxiety was tangible. I said I imagined that would be a frightening experience. He smiled and agreed: "It's not very nice." He had no other symptoms.
By now I had two provisional diagnoses: Bell's palsy and a cerebrovascular accident (CVA).
The facial weakness affected his eyelid and mouth but not the forehead, which would be unusual with Bell's palsy, which affects the facial (7th cranial) nerve. There was also no numbness, but I had never seen so recent an attack and was unsure whether the paralysis was still progressing.(1)
If Eric was having a stroke the paralysis would be related to an area of brain tissue rather than one specific nerve distribution, and could explain his dysphagia (problem swallowing). Eric's dysphasia (slurring) seemed to be a mechanical deficit due to the paralysis rather than a cerebral deficit, since his receptive and cognitive skills were unaffected.
I put my two theories to him. He did not reply, but for the first time turned his gaze away. I asked if I could take his blood pressure. He quickly took off his jacket and rolled up his shirt sleeve. His blood pressure was 166/104, and I gently told him it was higher than normal. He said he had hurried to the surgery carrying the shopping, so it would be. CVA is usually immediately followed by hypertension, which generally settles spontaneously.(2)
I told Eric I would try to contact the duty doctor for advice, and asked him to wait. The doctor quickly answered my call but said he would not be back for some time and that if I was concerned I should call an ambulance. I would have preferred a second opinion on my diagnosis - yes, I was concerned but not confident as to which of my diagnoses was correct. Eric needed someone with more knowledge than me, but if he had Bell's palsy it would be a waste of emergency services to call an ambulance. Also, I did not want to appear incompetent. Things would be much worse if he was having a stroke that progressed and I had not got him to hospital.
I called an ambulance. However, I realised I had not obtained his consent. This became more of a problem when he loudly repeated "No!" I explained that he had come for help but I could not provide it, so I was moving him to where help was available. I asked if there was anyone to contact at home, realising I should have done this sooner. His cat was at home. He did not know his neighbours and had no family nearby. I asked if he could think of anyone who would feed his cat if he were to be admitted. After some thought he suggested Cats Protection. This felt more like acquiesence and I went to find a telephone directory. We found the number and I wrote it down for him to take with him. The ambulance arrived, and I explained Eric's story to the crew. One of the ambulancemen said it was probably Bell's palsy. I felt guilty for overreacting and upsetting Eric. Still, he picked up his shopping and was loaded into the ambulance.
He was admitted for four days after his stroke was confirmed. It did not progress, but he is now on aspirin, atenolol and a statin.

References

  1. Kumar P, Clark M, editors. Clinical medicine. 4th ed. London: WB Saunders; 1998.
  2. Haslett C, Chilvers ER, Hunter JAA, Boon NA, editors. Davidson's ­principles and practice of ­medicine. 18th ed. London: Churchill Livingstone; 1999.