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The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians, but are nonetheless important to accurately recognize. Test your diagnostic and treatment skills using the following patient scenario and corresponding questions. If you have a case that you would like to suggest for a future Case Challenge, please email us at ccsuggestions@medscape.com with the subject line "Case Challenge Suggestion." We look forward to hearing from you.
Background
A 42-year-old man, married and with two teenage children, visits his primary care physician for an evaluation after three episodes of slurred speech and right arm weakness, each lasting for approximately 12-24 hours, during the past month. The patient is accompanied by his wife, who witnessed the most recent episode.
The patient says that immediately prior to the first episode, he felt dizzy during the day but can't remember anything else about the episode. His teenage son came home around 3 PM from a summer job and noticed the patient asleep and slumped over in a chair with a few empty beer bottles nearby, but did not wake up the patient. When the patient's wife came home, she also left him to take a nap for a few hours, and then asked him to get up and go to bed. His speech was slurred, his right arm felt tingly, and he could not raise it. He said that he would come upstairs, but he stayed in the chair overnight. When he woke up the next morning, his speech was no longer slurred and he was able to move his arm again.
The second episode happened while the patient was at work. The patient reported that he shared several beers with his coworkers to thank them for picking him up for a carpool that day. After drinking, he again developed slurred speech with right arm weakness. His supervisors told him that he could rest in the truck until he was ready to come back to work again. He fell asleep and his colleagues dropped him off at home after their workday was over. He was able to walk into the house. His speech was still slightly slurred and his right arm strength was improved.
The third episode occurred while he was at home with his wife on a weekend evening. After consuming several beers, the patient slumped over in his chair and fell to the ground. His wife called 911. The patient was seen in the emergency department, where he was noted to have slurred speech and right arm weakness. He had a brain CT scan, taken approximately 8 hours after the episode started. He started to recover after the CT scan, which was normal. He was told that he might have had a transient ischemic attack (TIA). He was given an order for an outpatient brain MRI and was told to see his primary care physician.
The patient had the brain MRI the day after his emergency department visit. He brought his films as well as the report to the primary care visit.
The patient works in construction. He does not smoke and says that he normally has one or two beers at home a few times a week. He says that he has been drinking a little more than usual because he is experiencing increased back pain and muscle stiffness, and the beer helps him relax. After work he also has been taking muscle relaxants, which belong to his father, who was prescribed them for lower back pain related to arthritis and left them behind at the patient's house.
The patient has a past medical history of eczema, for which he uses topical cream as needed. Pertinent family history: His mother has heart disease, and his father, as noted, has arthritis. His siblings and his children are healthy, with no medical history.
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Cite this: Heidi Moawad. Stroke-Like Episodes While Drinking Alcohol - Medscape - Sep 05, 2024.
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