Natalie Izumab
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You are the FY1 working in Accident and Emergency. You are asked to review a patient who has been pre-alerted in. All you know is that she is a 50 year old lady who has suddenly experienced slurred speech, and weakness down her right hand side.
HPC You are 50 years old and work as a GP receptionist. You arrived at work as normal today, only stopping for your morning cigarette. You stopped for a coffee break at 10:30, but when you got up to walk into the kitchen, you walked into the right hand side of the doorway, which is strange, because you didn’t feel dizzy or anything, and normally your vision is perfect with contact lenses. When trying to make your coffee, you dropped your mug on the floor and found you couldn’t grip things properly with your right hand. Your leg felt a bit numb as well, but put both symptoms down to a trapped nerve. A patient arrived at the desk to sign in at 10:45, but you realised you were struggling to get your words out. You started to feel anxious, but when you got up to find your colleague in the office, your right leg felt weak and collapsed underneath you. A passing FY2 on GP rotation came to help you, and noticed you were having difficulty speaking, and the right side of your face was drooping. They called 999 to have you urgently transferred to A&E. The ambulance arrived at 11:00, and you arrived in A&E at 11:08, 38 minutes after the first time you noticed symptoms. Luckily your husband arrived at A&E shortly afterwards to help give the history.
PMH You have a past medical history of type 2 diabetes on metformin and pioglitazone and gliclazide, but you confess you do treat yourself to a packet of biscuits every now and then. You are also hypertensive taking valsartan, and also take pravastatin for your cholesterol. Previously, you have had a cholecystectomy, and a mole removed from your back.
SH/DH You used to smoke 20 cigarettes per day since you were 15 years old, but over the past 2 years have gradually cut down to around 5 cigarettes per day. You live with your husband in a 2-storey semi-detached house, and you are both independent, mobile, and in full time work. You have two grown up children who are 28 and 25; you have still not quite managed to get the younger one to leave home. You drink a couple of glasses of wine approximately 3-4 nights per week.
FH Your father was diabetic and died of a stroke in his 60s; your mother has ischaemic heart disease and has recently had an aortic valve replacement and coronary artery bypass graft. Your paternal uncle also had a stroke in his 50s and has residual weakness.
Observe the student taking a history and prepare appropriate feedback.
They could justify performing any of the following examinations: cranial nerves with particular attention to II, III, IV and VI, upper or lower motor neurological. A sensory examination is perhaps less appropriate.
Ask them to provide a summary of their history and a differential diagnosis.
You may also want to tell them there are examination findings of; Right homonymous hemianopia, Expressive dysphasia, Right sided facial weakness, Bulbar weakness with unsafe swallow, Dense flaccid right sided arm and leg weakness.
Differential diagnosis should obviously include acute stroke, either ischaemic or haemorrhagic. The pattern isn’t quite right for MS, but you could include hemiplegic migraine.
Points for discussion • What immediate investigations should you do? • Why must this be done immediately? • What is your time limit in this situation? • What are the management options for patients presenting within this time limit? • What are the management options for patients presenting outwith this time limit? • What would you look for to differentiate between types of stroke? (PACS/LACS/POCS/TACS)
