Tingling tongue

Tingling tongue and hand:- Should a stroke be suspected?

I am asking a question about a patient I saw in order to improve my patient care as a family physician. There is no court case or legal battle, this is only for my personal learning. This happened a while ago and the patient was not upset but I only was told about the outcome recently.

In reviewing the case, please tell me the exact point of where I should have been more careful, what to base the decision on to decide that, and what would have been the most appropriate management. A nurse practitioner initially saw the case but consulted me.

The patient was a 65 yo female. She had hypertension and had been off her meds for some time (maybe up to 2 months but at least a week or two). She complained of having a bit of tingling in her hand and a tingling tongue (the tip of her tongue). She had no symptoms when I saw her, she complained of no tingling and her neurological exam was completely normal. She was very reluctant to go to the hospital. Her BP was 190/100 on her visit. We put her back on her two blood pressure meds and gave her all the information on signs and symptoms of stroke for her and her daughter. She was to follow up for her blood pressure measurement but never did. 3 days later she had some weakness on one side and called the ambulance. She had a stroke. Luckily it was very mild and she has almost completely recovered.

I have an idea but I want to learn the answer from someone who has more knowledge in the area and not just from reading, although I will read further under your guidance. I do my best, this happens to be the first time that I am aware of something that I could have made a better choice about. I did not consider that she had had symptoms before and that it may have been a while she was off the blood pressure meds. What would have been different had I sent her sooner? Also that she may not be reliable for follow up, that she may not even take the meds as asked (even after discharge, she has been going on and off her meds). Please, if you could answer my question I would really appreciate it. It could help me better serve the next patient I have with a similar story. thanks very much.

Thanks for your question.

Assuming the tingling tongue symptoms were on the same side as the sensory disturbance in the hand, then I think the main clue that the symptoms reflected a physical problem within the brain is the fact that the sensory symptoms localize to roughly the same region in the brain. As you will see from the diagram of the sensory representation of the brain shown on the right (the "homunculus") the area of cerebral cortex receiving sensory information from one side of the tongue is very close to the area supplying sensory information from the hand on the same side. This means that the entire region is likely to be supplied by the same blood vessel ans that symptoms occurring simultaneously in these 2 regions may be readily attributed to a vascular insult (a stroke ).

Hope that helps.

Stroke expert 3

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