Navigating Stroke Diagnosis Challenges in ETOH Abuse Patients

Case Overview

This case study involves an adult patient, approximately 60 years old, who presented to the emergency department (ED) with complaints of abdominal pain and constipation persisting for two weeks.

The patient’s past medical history was significant for Cerebrovascular Accident (CVA), Hypertension (HTN), Hyperlipidemia (HLD), Chronic Obstructive Pulmonary Disease (COPD), Peripheral Vascular Disease (PVD), Gastroesophageal Reflux Disease (GERD), Hepatitis C, and a history of Ethanol (ETOH) abuse.

Upon arrival at the ED, the patient exhibited aggressive behavior and lost control of their bowel and bladder functions. After evaluation and workup, they were discharged. Police intervened after the patient refused to leave the hospital grounds. During this episode, the patient was restrained and placed in a police vehicle, but later was found unresponsive.

The patient was immediately transported back to the ED where they suffered cardiac arrest during further examination and ultimately passed away. An autopsy revealed that the cause of death was a large left-sided ischemic stroke with hemorrhagic conversion.

Questions to the Emergency Room expert and their responses

How often do you treat patients with abdominal complaints and combativeness?

As a board-certified emergency medicine physician with over ten years' experience, I frequently encounter patients presenting to the ED with various complaints, including combativeness.

What are some possible etiologies for a patient with a history of ETOH abuse who presents with abdominal pain and combativeness?

Patients with a history of ETOH abuse presenting with abdominal pain and combativeness could suffer from numerous conditions. These include acute intoxication, alcohol withdrawal, substance abuse, porphyria cutanea tarda, Diabetic Ketoacidosis (DKA), Hyperglycemic Hyperosmolar Syndrome (HHS), alcohol ketoacidosis, or even neurological issues.

How does long-term ETOH abuse complicate stroke diagnosis?

Diagnosing a stroke in a patient with a history of ETOH abuse can be complicated. If the patient has slurred speech, it’s crucial to determine whether this is due to acute intoxication or neurological injury. This requires careful physical examination and lab tests and imaging. In many instances, ETOH intoxication becomes a diagnosis of exclusion.

About the expert

This expert is a board-certified emergency medicine physician with over a decade of experience, including specialized training in pre-hospital emergency medicine. They have held several key positions at a university, such as the medical director of an EMS service and an associate professor of emergency medicine. Their extensive involvement in professional organizations like the National Association of EMS Physicians and the American College of Emergency Physicians further underscores their expertise and commitment to the field.