Intro to Neuro Case Study 2

History of Presenting Condition

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

Vitals:

  • BP 140/90 mmHg
  • Pulse Regular

Physical Exam:

  • Slurred Speech and Confusion
  • Motor Weakness Left UL 0/5, LL 2/5
  • Decreased Tone
  • Altered Sensation
  • Altered Proprioception
  • Mild Left Sided Neglect

NIH Stroke Scale: 16

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
Total Score 16

Past Medical History

Mild Hypertension for 2 years

Hysterectomy 12 years ago (Aged 42)

Social History

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

Diuretics to manage Hypertension for 1 year

Previous Hx Hormone Replacement Therapy - Stopped 3 Years ago

Investigations

CT:

  • Right Sided MCA Superficial Area Ischemia 
  • Size < 1/5 Area

Labs:

  • INR 1.1
  • PTT 29.3 secs

Medical Management

Thrombolysis Discussed with Family & Patient

Prescribed and Initiated within 95 Mins Symptoms

24 Hours Monitoring

Referral MDT for Assessment within 48 Hours - OT, SLT & PT 

Physiotherapy Initial Objective

Muscle Strength: Left UL 0/5 and LL 2/5, Right UL & LL 5/5

Tone: Decreased Tone Left

Inattention: Mild to Moderate Innattention/Neglect Left Side

Cognition: Follows 1 - 2 Stage Commands

Transfers: Dependant on 2 for Transfers - Secondary to Left Inattention/Neglect

Speech: Unclear - Moderate Dysarthria

Swallow: Awaiting SLT Assessment - Coughing with Liquids - Following Assessment requires Thickened Liquids

Functional Assessment: Functional Independence Measure

Levels

Independent

7 Complete Independence (Timely, Safely)
The person performs all of the tasks described as making up the activity within a reasonable amount of time, and does so safely without the need for modification, assistive devices or aids.

6 Modified Independence (Device)
One or more of the following may be true:
a) Uses an assistive device
b) Takes longer than the reasonable amount of time
c) There is some concern for safety

No Helper

Modified Dependence

5 Supervision (Subject = 100%+)
Receives no more than stand-by cueing, coaxing or verbal prompting without physical contact, OR help just to set-up equipment, apply orthosis, etc.

4 Minimal Assist (Subject = 75%+) 
No more help than touching. Receives incidental help only to complete the task.

3 Moderate Assist (Subject = 50%+) 
Receives moderate help - Hands on help but patient does more than half the task themselves

Complete Dependence

2 Maximal Assist (Subject = 25%+)
Receives Substantial Assistance - Patient does less than half the task themselves, but does contribute

1 Total Assist (Subject = less than 25%) 
Receives total assistance - Patient unable to contribute or does very little of the task

Helper
Note':' Leave no blanks. Enter 1 if patient is not testable due to risk.


Admission Goal Discharge
Self-Care
  • Eating
5
  • Grooming
3
  • Bathing
3
  • Dressing - Upper Body
2
  • Dressing - Lower Body
2
  • Toileting
3
Sphincter Control
  • Bladder Management
3
  • Bowel Management
3
Transfers
  • Bed, Chair, Wheelchair
2
  • Toilet
2
  • Bath/Shower
2
Locomotion
  • Walk/Wheelchair
2
  • Stairs
1
MOTOR SUBTOTAL SCORES 33
Communication
  • Comprehension
6
  • Expression
4
Social Cognition
  • Social Interaction
6
  • Problem Solving
4
  • Memory
4
COGNITIVE SUBTOTAL SCORE 24
TOTAL FIM SCORE 57