Stroke:Case Study Section 3

Introduction

This case study forms part of the Stroke Course

History of Presenting Condition

Michael is a 61 year old Senior Partner in a Law Firm. While eating breakfast Michael experienced sudden onset slurring of speech, had facial droop on his left hand side with weakness in left side upper and lower limbs. Michael's wife Mary spotted these sudden onset of symptoms and immediately called for an ambulance, which arrived within 15 mins.

Past Medical History

Asthma - Dx Aged 8

Hypertension Grade 1 - Dx 5 years ago

Prediabetes - Dx 3 years ago

Medication History

Seretide Accuhaler

Ventolin (As Required - Not Required for over 1 Year)

Thiazide

Social History

61 Year Old Senior Partner at a Law Firm, recently reduced working hours 20 - 30 hours per week, previously worked 50 - 60 Hours

Planning on retirement in 1 - 2 years

Lives in a Bungalow with his wife Mary, who is a recently Retired Teacher.

2 Adult Children, both married with their own children - 1 lives close by, the other lives overseas.

Lifestyle Changes implmented over past 2 - 3 Years foloowing Dx Prediabetes.

Outside work he enjoys golf, usually playing at least 2-3 per week. Also enjoys playing Bridge with Friends.

Took up walking 3 Years ago following Dx Prediabetes. Walks 5 - 6 days per week for between 30 - 45 mins

Ex-Smoker - Hx Smoking 30 Years x 10 - 15/day - Quit 3 Years ago following Dx Prediabetes

Social Beer Drinker 10 - 15 Standard Drinks per week with 3 - 4 per session, although sometimes after Golf may be more.

Pre-Hospital Assessment

Vitals:

• BP 140/90 mmHg
• Pulse 75
  

Physical Exam:

FAST +ve

• Left Facial Droop
• Left Motor Weakness: Upper Limb 0/5, Lower Limb 2/5
• Slurred Speech 

Pre Hospital Assessment Scale:

Los Angeles Prehospital Stroke Screen (LAPSS) & Los Angeles Motor Scale (LAMS)

Criteria	Yes	No	Unknown
1. Age greater than 45 years	Yes
2. History of Seizures or Epilepsy		No
3. Onset of Neurological Symptoms is less than 24 hours	Yes
4. Patient was Ambulatory prior to onset of symptoms	Yes
5. Blood Glucose between 60 and 400 mg/dl	Yes 125mg/dl
6. Motor Exam: Examine for Motor Asymmetry     Based on Exam below, patient has Unilateral 'Weakness:	Yes
	Equal	Right	Left	LAMS SCORE
Facial Smile / Grimace			Droop	1
Grip Strength			No Grip	2
Arm Srength			Falls Rapidly	2
				5

Acute Hospital Assessment

Vitals:

• BP 145/90 mmHg
• Pulse 82

Physical Exam:

• Confusion
• Left Facial Droop
• Slurred Speech 
• Left Motor Weakness Upper Limb 0/5, Lower Limb 2/5
• Decreased Tone
• Altered Sensation
• Mild Left Sided Neglect

Acute Assessment Scale:

NIH Stroke Scale: 16

Level Of Consciousness	1
LOC Questions	2
LOC Commands	1
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	2
Extinction & Inattention	1
Total Score	19

Investigations

Labs:

• INR 1.2
  

CT:

• Hyperdensity Right Middle Cerebral Artery - Superior Division
• Size < 1/5 Area
  

MRI:

Loss of flow signal in the Right Middle Cerebral Artery consistent with Acute Occlusion by Thrombus

Medical Management

Thrombolysis:

• Discussed with Family & Patient
• Prescribed and Initiated within 120 Mins Onset Symptoms
  • Intravenous rTPA

Stroke Unit:

• Admitted to Acute Stroke Unit
• 24 Hour Monitoring
• MDT Referral Received within 24 Hours - OT, SLT & PT

Physiotherapy Objective

Physiotherapy Management