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Q 1. A 64 year old man comes to the Emergency room with the chief complaint of weakness in his right arm and leg that lasted 3 hours. His wife forced him to come to the ER. He feels fine now and wants to go home. He is on no medication. He lives on the third floor of a building that does not have an elevator. He denies any chest pain or shortness of breath. He has been a healthy man all his life and has no family history of stroke or Coronary artery disease. His examination, including labs and EKG are normal. A carotid artery ultrasound and doppler reveals 70% stenosis in the left internal carotid artery. What should you do next?
The most appropriate answer is choice 4. This is a patient who has already performed well on a daily activity stress test. He certainly needs a carotid angiogram as the next step. Only after that is confirmed to be positive and the patient needs surgery, a cardiac evaluation is needed. For that - a stress test is good enough. The boards do not want you to take the shotgun approach. It is a well known fact that the two surgeries- carotid endarterectomy and CABG (Coronary artery bypass graft) should be done in the same sitting if both are needed. Q 2. He undergoes surgery on his carotid artery and is sent to the surgical ICU. Few hours after the surgery, he wakes up and you examine him after his nasotracheal tube is removed. You ask him to stick his tongue out. His tongue is deviated to the left side. What has happened to him?
The correct answer is choice 2. This patient is suffering what is an expected finding after a CEA (Carotid end-arterectomy). The tongue can remain deviated to the side of the surgery for 24-48 hours. If it were deviated to the opposite side, it would be abnormal. |