Intro to Neuro Case Study 2: Difference between revisions
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*Pulse Regular | *Pulse Regular | ||
'''Physical Exam:''' | '''Physical Exam:''' | ||
*Slurred Speech and Confusion | *Slurred Speech and Confusion | ||
*Motor Weakness | *Motor Weakness | ||
UL 0/5, LL 2/5 | UL 0/5, LL 2/5 | ||
*Mild Left Sided Neglect<br> | *Mild Left Sided Neglect<br> | ||
'''NIHSS: 14''' | '''NIHSS: 14''' | ||
{| width="80%" border="1" cellpadding="1" cellspacing="1" | {| width="80%" border="1" cellpadding="1" cellspacing="1" | ||
|- | |- | ||
| Level Of Consciousness | | Level Of Consciousness | ||
| 1 | | 1 | ||
|- | |- | ||
| LOC Questions | | LOC Questions | ||
| 1 | | 1 | ||
|- | |- | ||
| LOC Commands | | LOC Commands | ||
| 0 | | 0 | ||
|- | |- | ||
| Best Gaze | | Best Gaze | ||
| 1 | | 1 | ||
|- | |- | ||
| Visual Field Testing | | Visual Field Testing | ||
| 1 | | 1 | ||
|- | |- | ||
| Facial Palsy | | Facial Palsy | ||
| 2 | | 2 | ||
|- | |- | ||
| Motor Function Arm Right | | Motor Function Arm Right | ||
| 0 | | 0 | ||
|- | |- | ||
| Motor Function Arm Left | | Motor Function Arm Left | ||
| 4 | | 4 | ||
|- | |- | ||
| Motor Function Right Leg | | Motor Function Right Leg | ||
| 0<span class="Apple-tab-span" style="white-space:pre"> </span> | | 0<span class="Apple-tab-span" style="white-space:pre"> </span> | ||
|- | |- | ||
| Motor Function Left Leg | | Motor Function Left Leg | ||
| 2 | | 2 | ||
|- | |- | ||
| Limb Ataxia | | Limb Ataxia | ||
| 0 | | 0 | ||
|- | |- | ||
| Sensory | | Sensory | ||
| 1 | | 1 | ||
|- | |- | ||
| Aphasia | | Aphasia | ||
| 1 | | 1 | ||
|- | |- | ||
| Dysarthria | | Dysarthria | ||
| 1 | | 1 | ||
|- | |- | ||
| Extinction & Inattention | | Extinction & Inattention | ||
| 1 | | 1 | ||
|- | |- | ||
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Past Medical History | |||
== Past Medical History == | |||
Mild Hypertension for 2 years | Mild Hypertension for 2 years | ||
Hysterectomy 12 years ago (Aged 42) | Hysterectomy 12 years ago (Aged 42) | ||
== Social History == | == Social History == | ||
Revision as of 14:33, 4 March 2016
History of Presenting Condition
[edit | edit source]
Jane is a 56 year old Chief Executive Officer and Partner in a small Accounting Firm. She was found on the floor by her husband, Sean, after he heard her banging on the bathroom door about 5 minutes after going into the bathroom to shower before work. When Sean found her in the bathroom she hasome confusion about what had happened, had difficulty with her speech which was slurred, had facial droop on her left hand side with weakness in both her left sided upper and lower limbs. Sean called for teh ambulance which arrived within 15 mins and transferred Jane to A & E where she was assessed by the Stroke Medical Team within 15 mins of arrival.
Presenting Condition[edit | edit source]
Vitals:
- BP 190/110 mmHg
- Pulse Regular
Physical Exam:
- Slurred Speech and Confusion
- Motor Weakness
UL 0/5, LL 2/5
- Mild Left Sided Neglect
NIHSS: 14
| Level Of Consciousness | 1 |
| LOC Questions | 1 |
| LOC Commands | 0 |
| Best Gaze | 1 |
| Visual Field Testing | 1 |
| Facial Palsy | 2 |
| Motor Function Arm Right | 0 |
| Motor Function Arm Left | 4 |
| Motor Function Right Leg | 0 |
| Motor Function Left Leg | 2 |
| Limb Ataxia | 0 |
| Sensory | 1 |
| Aphasia | 1 |
| Dysarthria | 1 |
| Extinction & Inattention | 1 |
Past Medical History[edit | edit source]
Mild Hypertension for 2 years
Hysterectomy 12 years ago (Aged 42)
Social History[edit | edit source]
Lives in a Two Story Dettached House with her Husband Sean, a Teacher, and two daughters, one in her final year at High School and teh other in her second year at University studying Law.
Partner and CEO Accounting Firm regulalry working 50 - 60 hours per week
Outside work she enjoys reading and music. Plays the guitar and is a member of her local choir.
Started walking regulalry 2 years ago to try to help with her Hypertension - Walks 3 to 4 days per week for 30 - 45 mins
Hx Smoking 15 Years x 10 to 15/day - Stopped 16 Years ago
Alcohol - Social Drinker 8 - 10 Units per week - Mainly Red Wine - No more than 2-3 Units per session
Drug History[edit | edit source]
Diuretics to manage Hypertension for 1 year
Previous Hx Hormone Replacement Therapy - Stopped 3 Years ago
Investigations[edit | edit source]
CT:
- Right Sided MCA Superficial Area Ischemia
- Size < 1/5 Area
Labs:
- INR 1.1
- PTT 29.3 secs
Medical Management[edit | edit source]
Thrombolysis Prescribed and Initiated within 90 Mins Symptoms
Referral MDT for Assessment within 48 Hours - OT, SLT & PT
