Intro to Neuro Case Study 2: Difference between revisions
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== Presenting Condition == | == Presenting Condition == | ||
Vitals: | '''Vitals:''' | ||
*BP 190/110 mmHg | *BP 190/110 mmHg | ||
*Pulse Regular | *Pulse Regular | ||
'''Physical Exam:''' | |||
*Slurred Speech and Confusion | |||
*Motor Weakness | |||
UL 0/5, LL 2/5 | |||
*Mild Left Sided Neglect<br> | |||
'''NIHSS: 14''' | |||
{| width="80%" border="1" cellpadding="1" cellspacing="1" | |||
|- | |||
| 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<span class="Apple-tab-span" style="white-space:pre"> </span> | |||
|- | |||
| Motor Function Left Leg | |||
| 2 | |||
|- | |||
| Limb Ataxia | |||
| 0 | |||
|- | |||
| Sensory | |||
| 1 | |||
|- | |||
| Aphasia | |||
| 1 | |||
|- | |||
| Dysarthria | |||
| 1 | |||
|- | |||
| Extinction & Inattention | |||
| 1 | |||
|- | |||
| | |||
| | |||
|} | |||
Past Medical History == | |||
Mild Hypertension for 2 years | |||
Hysterectomy 12 years ago (Aged 42) | Hysterectomy 12 years ago (Aged 42) | ||
| Line 20: | Line 81: | ||
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. | 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 | 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. | Outside work she enjoys reading and music. Plays the guitar and is a member of her local choir. | ||
| Line 28: | Line 89: | ||
Hx Smoking 15 Years x 10 to 15/day - Stopped 16 Years ago | 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 | Alcohol - Social Drinker 8 - 10 Units per week - Mainly Red Wine - No more than 2-3 Units per session | ||
== Drug History == | == Drug History == | ||
Diuretics to manage Hypertension | Diuretics to manage Hypertension for 1 year | ||
Previous Hx Hormone Replacement Therapy - Stopped 3 Years ago | Previous Hx Hormone Replacement Therapy - Stopped 3 Years ago | ||
| Line 40: | Line 101: | ||
'''CT:''' | '''CT:''' | ||
Right Sided MCA Superficial Area Ischemia | *Right Sided MCA Superficial Area Ischemia | ||
*Size < 1/5 Area | |||
'''Labs:''' | |||
*INR 1.1 | |||
*PTT 29.3 secs | |||
== Medical Management == | == Medical Management == | ||
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Thrombolysis Prescribed and Initiated within 90 Mins Symptoms | Thrombolysis Prescribed and Initiated within 90 Mins Symptoms | ||
Referral MDT for Assessment within 48 Hours - OT, SLT & PT | Referral MDT for Assessment within 48 Hours - OT, SLT & PT | ||
== Physiotherapy Initial Assessment == | |||
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 ==
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
