1 Stroke Case Scenario – Bob Brown
Handover (ED to Ward 7F- Neurology) 27th April 2020 @ 10.30:
MRN: 432 755 DOB: 17.04.1953
Introduction – This is Bob Brown, a 67 year old male who was brought in by ambulance following a collapse at home. Bob’s daughter who was visiting at the time, did not witness the fall, but had found Bob with a decreased level of consciousness on the floor, confused speech experiencing dysarthria and appeared to have left-sided weakness and facial droop. Bob’s daughter accompanied him to the Hospital.
Situation – On examination in the ED upon arrival on the 26th April 2020 at 12.15 hrs, Bob had a global aphasia, right gaze deviation, left-sided facial droop, dysarthria, and left-sided limb weakness. Bob was a stroke call and was transferred immediately to have a CT Brain Non-Contrast which excluded the potential of haemorrhage. CT angiography confirmed a right middle cerebral artery (MCA) occlusion. Bob’s confirmed diagnosis was R MCA territory acute ischaemic stroke. He was administered with Intravenous thrombolytic treatment known as Alteplase (tPA) two hours from symptom onset @ 13:00 hrs. Bob was not a candidate for digital subtraction angiography and did not require Thrombectomy or stenting and was transferred to the Neurology Stroke ward. The following day, he had only a very mild expressive aphasia and left facial droop upon examination. Although recently, Bob has become agitated and impulsive within the stroke unit and is shouting loudly for his daughter. Bob failed a sip test and remains NBM awaiting a Speech Pathology consult.
Background – Lives alone, but is fairly independent. PMHx hyperlipidaemia, hypertension (HTN), managed well with metoprolol, history of vertigo – no current medications and Type
AIDiabetes Mellitus (T2DM) (Diet controlled), ETOH (Ethyl alcohol) abuse known – usually drinks a 1L bottle of vodka per week.
2
Assessment – Observations are as follows
-BP 168/86
-HR 98 BPM (Sinus Rhythm)
-SaO2 97% on RA
-RR 19
-Temp 36.9⁰C
-GCS 13/15 (E=3, V=4, M=6)
Recommendations – The Interventional Neuro Radiology team clinical plan as stated from the operation report for Bob are as follows:
Observations as per Stroke Pathway and Thrombolysis guidelines
30 Minute Neuro Obs for 6 hours then hourly Neuro Obs for the remainder of the 24 hour period post Alteplase administration, then 4/24
30 Minute Vital signs for 6 hours then hourly Vital signs for the remainder of the 24 hour period post Alteplase administration, then 4/24
No Indwelling Catheter (IDC) Nil By Mouth
Speech Pathology Review (Due to failing ASSIST swallow screen) Falls Risk assessment please
Consider Alcohol Withdrawal Scale (AWS) Pathway Cardiac monitoring
IV fluids as charted
PRN analgesia as charted IVC as required
Any decline in more than 2 points GCS, please notify Between the Flags observations parameters please
3
Additional: He is concerned about his dog at home and has requested to phone his neighbour or daughter as soon as possible to gain an update on the home situation.
Charts available:
SAGO
Neurological Observations AWS Chart
Fluid Balance Chart Fluid Order
Medication Chart