Medical Questions: Stroke, Clots, High Blood Pressure

So I’m going through the rudiments of Caring For Your Aging Parent 101. My dad has been confused for a while (not severely), and fell during his mall walk about a month ago. He exhibited signs of aphasia, and had a fat leg. I persuaded him to see a doctor, and he found a clot in his leg.

We also had an MRI done, and they found that my dad had a small stroke (not a TIA…the doctor characterized it as a small stroke with irreversible damage). He also said he has artherosclerosis.

The doctor didn’t say what part of the brain the stroke affected. After a month on the coumadin, the swelling is gone and the doctor prescribed aspirin therapy and told my dad he could resume normal activities (which includes mall walking and drumming…which my dad does for enjoyment and cardio workout). He will continue the coumadin for 3-6 months.

His doctor seems to be too busy to do his job (i.e., not explaining one fucking thing without me having to come up with every single fucking question). I get a vibe that he doesn’t like when I ask questions (not that I care, but I don’t know if I’m asking the right stuff all the time).

So…I have a couple questions:

  1. I need to know if I should be seeking a 2nd opinion or if this looks like the correct course of action. I’ve seen ads on tv about artherosclerosis and a drug that is supposed to help, but the doctor acted like he’s never heard of it before. He wanted me to come up with the name of the drug (which of course I couldn’t) and was just rather unhelpful with my question. I don’t know if another medication would be better than aspirin therapy.

    a) My dad is on high blood pressure meds, and has been for at least 10 years. His BP was 130/90-ish a month ago, and 170/something-ish yesterday. The doctor didn’t prescribe any change to that medication. I think he may have been nervous about the MRI results, but ??? … who knows?

    b) My dad is on the “booster pill” for diabetes. His numbers are consistently in the 130 and below range, usually 110-120-ish.

    c) I wasn’t able to find a “geriatrics specialist” or a “vascular medicine specialist” in our area in the Medicare listing or in the Yahoo yellow pages. Is there some other kind of doctor I should be looking for for a 2nd opinion, if I even need one?

    d) Is the doctor being a dick or am I being overly concerned?

Thanks. I really appreciate any insight you doctor types can offer. I want to be sure I’m going in the right direction (or if Dr. Too Busy is!).

Hey, Kalhoun, we don’t always (normally?) agree, but in this case it does sound like your doc has some ‘splainin’ to do…of course since I don’t know you, maybe it is you are incredibly annoying. :wink:

Let me try and sort out a few things, and we’ll go from there.

A “clot in the leg” usually means a clot in the vein. These are almost never the cause of a stroke, b/c the lungs filter out those clots if they break off. They only get to the brain is as a “paradoxial embolus” related, say, to an unrecognized hole between the two sides of the heart (an atrial septal defect would be an example). Less likely (but possible) to sit there unrecognized until you are old, so his leg clot and stroke are probably not directly related.

Leg vein clots can be superficial and deep. Deep ones usually get coumadin for awhile, then an antiplatelet agent. Aspirin and Plavix (clopidogrel) are common ones.

Aspirin and Plavix are also used for problems on the arterial side–stuff like TIAs and stroke prevention and so on. They are not mutually exclusive.

A full discussion of what to use when and for how long and how much is way beyond a post here, so I’ll move on to your next issues.

No one knows what to do with blood pressure in the elderly. In general, lower blood pressure is good and higher is bad, but control of systolic hypertension (the upper number) in people with atherosclerosis is problematic. The arteries stiffen as you get older. Think of a pulse of fluid injected into an iron pipe instead of a rubber one–higher spikes. So you end up playing off the side effects of meds against a blood pressure number. Again, beyond the scope of this post.

The blood glucose numbers look pretty good. There are ways to see what his average number is–a Hemoglobin A1C, for example–that give better information than an isolated number. Same problem as BP–too tight control can have its own issues, even though tight control is better over time.

What kind of doc? Well, what’s he got now? He needs a good Internist or a good Family Practitioner. The good ones will know when to farm him out to a specialist and how to coordinate care. Doesn’t have to be a specialist. Doesn’t have to be a geriatrician. Has to be comfortable with the elderly. I wish I knew how you choose a good doctor, and I am one ( a doctor and a good one :slight_smile: ). We just sort of know, within our own circles.

I’ve looked over this post, realized it’s completely useless, and ask for your forgiveness in advance.

Thanks for setting that aside…this is my daddy-o we’re talkin’ about here. Otherwise, I’m available to receive your ridicule and/or scorn as you see fit.:wink:

Okay, that’s very useful to me. He mentioned the lung thing, but never mentioned that the stroke was probably not related to it.

Again, this is useful. I think I understood him to say that the coumadin doesn’t help the stroke thing, but the aspirin would be helpful in both situations.

I assume that both the HBP and the blood glucose numbers are contributors to the other issues overall, but that independently, the Dr. feels that he’s doing ok. Is that pretty close?

I’m syre this guy is a GP. Now that I know he doesn’t need a specialist, I’m sure I can find someone who digs the geezers (this dude is SO not da man). I just wasn’t sure if these new issues required a specialist.

Actually, this was quite useful to me. Thanks a mil!

IANAD but have some experience in the area so I thought I’d fill up space until a real doc comes along.

My dad has similar issues and got the best care with an interventional cardiologist who also specializes in peripheral vascular disease. I think the drug you might be thinking of is Plavix (an antiplatelet). My dad is on this. If your dad had a stroke because he threw clot, he should probably be on some kind of antiplatelet therapy…which should also help with the deep vein thrombosis (I am assuming that’s the diagnosis for his leg?) They also put an IVC filter in my dad to prevent pulmonary embolus (a filter they put in the vena cava which will trap any big clot before it embolizes to the lungs).

Also do you know what kind of stroke he had? I am assuming it was an embolic event and not hemorrhagic since they have him on coumadin and aspirin but it’s probably a good idea to ask if you haven’t already.

Anyway I’d get him under the care of a cardiologist (preferably an interventional one who also does peripheral work).Either that of a vascular surgeon. They will communicate with his GP to make sure everything is kosher with all the other meds he is on for diabetes etc.

They didn’t say what kind of stroke it was. See…this is what’s making me a little crazy. Based on what the Chief said, it was probably not the leg clot that caused the stroke, and the two were diagnosed like a month apart. I was noticing symptoms of the stroke and talked him into making an appointment with the doctor, and then the morning of the appt., he told me about the fat leg.

The doctor didn’t seem to think surgical intervention is necessary right now (though it would sure as hell put my mind at ease if I knew there was something to catch anything that breaks off). In fact, I was surprised he told him he could drum again, what, with the jiggy feet and all that’s involved with that.

So, I guess this was just two independent issues that came down at the same time?

Wouldn’t a cardiologist only be involved if there were specific heart issues involved?

A clot in the leg would be on the venous side and is usually the result of deep vein thrombosis (that was the cause in my dad’s case). The stroke would be unrelated since it is on the arterial side BUT both clots can have the same underlying cause- peripheral vascular disease- which is why when my dad had these issues, they sent him to a doc who specialized in peripheral vascular disease. In his case that specialist was a cardiologist, but a vascular surgeon would also be qualified. I should add that my dad is a retired MD so other docs are less likely to brush off his questions/concerns (which is total bs imo, they should give outstanding service to everyone).

FYI the IVC filter is put in percutaneously (IOW they don’t have to cut you open/no surgery required).

To diagnose his DVT in his legs they used ultrasound. Once diagnosed they put him on antiplatelets, put an IVC filter in, and gave him these compression hose (very tight socks) that he has to wear all the time.

As for the stroke: Did they do an angiogram on your dad? They did this on my dad and were able to tell that his carotid arteries were occluded…they ended up putting a stent in his rt carotid to open up the vessel and prevent future strokes.
In my dad’s case, it was the same underlying disease that caused both the clots in his legs and the clots in his carotid arteries to form (clots in the carotid arteries will lead to stroke if they embolize whereas clots in the leg veins can lead to pulmonary embolus). So they are treating him with systemic antiplatelets, which according to his doc help to prevent formation of clots everywhere in his body. Then they used the various mechanical devices (stents, IVC filter, compression hose) to treat the specific sites.

I have a horrible head cold, so I hope this is coherent.

Ahem…I am more than a little wounded, particularly since it’s only been a few weeks since I passed my most recent Board recert (and may I say, by a very robust margin :slight_smile: ) so the American Boards of Internal and Emergency Medicine both think I’m a real doctor…

Back to the stroke thing: if it was found on MRI and not fresh, whether it was embolic (something broke off somewhere else between the heart and the brain and traveled up to a brain vessel) or thrombotic (local closure) is not discernible. It was not hemorrhagic (local bleeding) because he was anticoagulated, and besides, the MRI would show that fairly well.

Now part of stroke workup does involve looking for a heart or carotid cause; usually as non-invasively as possible. More recent technology in some institutions can give very good non-invasive evaluations before turning to procedures like ordinary angiograms.

But here’s the thing, Kalhoun, and this is actual medical advice here on the Dope–highly unusual for me: start by getting Pa a good captain. Do not start by trying to figure out from your lookers-on which specialist to go to. First of all, any good Internist or Fam Practitioner can get him to the right specialist. Second, specialists are very focused. So the Vascular guy says, "Well; it’s not his carotid. Let’s see what the Cardiologist says. And the Cardiologist says, “Well; it’s not a valve veggie or a fib; let’s see what the Neuro guy says.” And the Neuro guy says, “Well; I don’t really know, but let’s just keep him on aspirin cuz even if we angio’d him we wouldn’t do anything at his age for a crappy Middle Cerebral.” And on it goes. Meantime the Diabetes is rolling along, the BP is bouncing around, he’s getting an assortment of symptoms you aren’t sure are significant. Then he gets pneumonia and none of the specialists are really interested in getting involved, so you truck off to the ED and get…me.

So, some advice. Start with a qualified captain. Let his personal physician get the right specialists, in the right order. While there is a tendency to want to go right to the “best,” in medicine no one is the best at everything. And three or four superb specialists do not cumulatively make a good personal physician.

:smiley: My apologies, Chief! You sure sounded like a doctor, but since you didn’t state it I assumed you weren’t (translation: if I had spent decades getting a degree, I’d be flaunting it ;)). Anyway I was just trying to offer Kalhoun the benefit of my experience since my own dad is dealing with the same issues. But now that I know he’s in good hands, I’ll move along. Carry on…

Ok, my understanding from the head MRI is that there is no evidence of a carotid thing going on (I assume they can see that, even though it’s often diagnosed via other techniques…right?). So when you use the term “captain”, you’re referring to Dr. Too Busy, right? I’ve got another issue here that makes me nervous. This guy’s partner is the one who told my mom she “probably had a little diverticulitis” when she reported rectal bleeding. Didn’t run tests until the bleeding was really, really bad, at which time he diagnosed colon cancer that had spread to the liver. Mom died 3 months later. :frowning:

Now…I’m not going to assume Dr. Too Busy is as bad as Dr. Prick, but I’m not sure what I should be saying to this guy. Am I supposed to ask if he’s done X, Y, or Z? Or should I just let him do his doctor thing and hope he’s not Dr. Prick in disguise? I really hate this shit. My dad’s not too proactive and although I’m designated Med. Power of Attorney, I’m not in the driver’s seat just yet. All I can do is discuss and suggest at this point. I’m concerned that I’m not going to be proactive enough, or pushy enough.

One more thing…my sister had a clot in her leg and she wore compression hose, however, the doctor didn’t ask my dad to wear them. What’s up with that? Are there circumstances where they wouldn’t need to? His clot was diagnosed via doppler imaging, so it’s definitely there.

My friend took her dad to a Nurse Practitioner who specializes in geriatrics. She said she gets great info, education, and coordination of care from th NP. Are there any good NP’s who will spend some time with you two in your area? Perhaps ypu would get better care form one than from Dr. Toobusy.

I can check with the hospital. I’ve never had an NP that wasn’t part of the practice. Are they listed as a “specialty?”

I can’t speak to the compression stocking accurately; it depends on how much venous incompetence there is.

And yes, by “captain” I mean it’s important to have a good general physician in charge rather than go right to specialists. It’s unfortunate yours has not been a very good one, if for no other reason than that he won’t take a moment to get questions answered. In the long run that saves him time, by having an educated person help out his patient.

An expert NP would be a reasonable choice but my own bias is that your Dad has enough significant problems to warrant an Internist or Family Practioner as the central guy/woman. There are a lot of subtleties to weigh, and equally important is a connection with the right qualified specialists, which a good doc should have.

Thanks, Chief. I’m going to compile a list of questions based on this info, and hopefully I’ll get on the right track with this guy – or find someone else who’s not Dr. Too Busy.

They usually work under a Dr’s license. That Doc reviews their charts and signs off on them if all is well, so you could get the more thorough care from the NP while officially belonging the NP’s Doc for, say, hospitalization issues.