Diagnose It Answer — April 6, 2026
ALL CLUES
71-year-old male brought in by his daughter with sudden onset right-sided facial droop, right arm weakness, and slurred speech that began approximately 90 minutes ago while he was eating breakfast. Daughter states 'his face just fell and he couldn't hold his fork.' Symptoms have not improved.
History of atrial fibrillation, hypertension, and hyperlipidemia. He is prescribed warfarin but admits he hasn't taken it consistently this past week. Last INR check was 3 weeks ago. No prior stroke or TIA. He has a pacemaker placed 2 years ago for sick sinus syndrome.
BP 188/102 mmHg, HR 88 bpm (irregularly irregular), RR 18 breaths/min, SpO2 97% on room air, Temp 36.8°C. NIHSS score assessed at 12, indicating moderate stroke severity. Patient is alert but dysarthric and cannot follow complex commands with his right hand.
FAST exam positive: facial droop right, arm drift right, speech slurred. Pupils equal and reactive. No gaze deviation. Left-sided strength and sensation intact. Right arm strength 2/5, right leg 3/5. Neurology and stroke team activated on arrival. Last known well time confirmed at 90 minutes — within tPA window.
Non-contrast CT head: no hemorrhage identified, no early ischemic changes. INR 1.2 (subtherapeutic — patient's target range 2.0–3.0). Platelet count 224,000/µL. Blood glucose 118 mg/dL. CT angiography head/neck: left MCA M1 segment filling defect consistent with thrombus. Patient eligible for IV alteplase; interventional neurology consulted for mechanical thrombectomy.
Ischemic stroke accounts for approximately 87% of all strokes and results from thrombotic or embolic occlusion of a cerebral artery. Atrial fibrillation is one of the leading cardioembolic causes — subtherapeutic anticoagulation dramatically increases stroke risk. The NIHSS is the standard neurological assessment tool used to quantify deficit severity and guide reperfusion decisions. IV alteplase must be administered within 4.5 hours of last known well time; mechanical thrombectomy extends the window to 24 hours for large vessel occlusions.
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