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Medical Clerking Neurology Dr Marcus Dawson on behalf of the BulgariaNetworknt Support Feel free to type questions in the chat to be answered at the end Please take the time to fill out our feedback form at the end of the talk Dr Marcus Dawson BSc MSc MRCP(UK) Medical registrar within the East of England deanery How to structure your assessment Very brief overview of stroke 01 Here you could describe the topic of the section02 Atypical Stroke When is a ‘stroke’ not a stroke 03 Summary and Questions 04 Who gets a stroke anyway? Patient A 67M retired office worker with HTN T2DM and a raised Risk Factors Ischaemic BMI develops speech difficulty when reading the menu at Diabetes (more so if poorly controlled) a restaurant finally attends A+E a day later as he doesn’t like going to the doctors. HTN (more so if poorly controlled) Age He is prescribed bisoprolol, ramipril, metformin Smoking Drinks alcohol and is an ex-smoker AF High cholesterol Thrombophilia Patient B 34F librarian from a northern European background with well controlled T1DM using a Libre device who is taking Haemorrhagic the oral contraceptive pill and insulin develops blurred ADPCKD vision more noticeable when looking to the left. Drinks minimal alcohol non-smoker. Family Hx Known cerebral aneurysm Connective tissue disorders How to examine A basic medical examination heart lungs abdo and legs A focused CN examination pupils equal and reactive to light (PEARL) CN II – VII A peripheral nerve exam tone power sensation Specifics for stroke palmer drift co-ordination (past pointing / heel-shin) dysdiadochokinesia Babinski’s How to What to look for Partial Anterior Total Anterior Lacuna Stroke Posterior stroke circulation stroke Circulation Stroke (PACS) (TACS) THREE of the following TWO of the following ONE of the following Unilateral ONE of the following Unilateral CN palsy + contralateral weakness/sensory weakness/sensory motor/sensory deficit of deficit of Pure sensory face/arm or leg face/arm or leg Bilateradeficit/sensory Pure motor Homonymous Conjugate eye Homonymous hemianopia Sensory-motor movement disorder hemianopia Cerebellar dysfunction Higher cortical Higher cortical Ataxic hemiparesis Homonymous dysfunction dysfunction hemianopia / cortical blindness Case one – History & Examination History Examination findings : Looks frail 94f care home resident found unresponsive at PEARL 06:45 last seen well at 04:00 GCS E3 V1 M4 = 8 Last dose of apixaban @20:00 yesterday Avoiding use of R arm R side facial droop Spontaneous movement of L arm Normal tone L arm hypotonia R arm Medications Planters: downgoing L upgoing R Apixaban 2.5mg BD HS S1 S2 + 0 Co-codamol 30/500 TT QDS Equal air entry / no added sounds Abdo SNT Laxido T BD Thiamine 100mg TDS Case one – Further management plan Now Much Later STAT 300mg aspirin (PO/PR/NG) MRI head NEVER anticoagulate Carotid dopplers Get an ECG IPC stocking (FlowTrons ®) Diabetic control Admit to stroke unit Smoking cessation Later Haemorrhagic stroke • Reverse any anticoagulants Add on HbA1C / lipid profile / • Refer to neurosurgeons Ca / B12 / folate / TSH Statin (Atorvastatin 80mg) • Neuro-obs +/- repeat CT SLT assessment +/- NG tube • Targeted BP control if BP optimisation hypertensive Differential Diagnoses (stroke mimics) Peripheral Space occupying Bells Palsy Neuropath TIA lesion STROKE EMERGENCIES Patient A Thrombolysis Unsuitable patient 59M who notices L arm Giving an infusion of Timing is everything weakness when waking up Alteplase to remove the at 7am to take his blood clot burden if within.5 hrs Lots of contraindications thinner medication Patient B Thrombectomy Suitable patient 69M who is a keen gardner Mechanical removal of The deficit has to develops L arm and leg obstructing clot in more significant enough to be weakness whilst walking proximal cerebral arteries worth the risk of the his grandchildren to school giving rise to big deficits procedure Summary CT head is used to rule out a haemorrhagic stroke Thorough history taking and (a pathological diagnosis) careful examination can unpick ?Stroke is a common admitting complaint to the medical team CT head may or may not show the stroke mimics an ischaemic stroke Urgent assessment is required to consider thrombolysis or thrombectomy Take your clerking to the next Medical management of stroke level by localising the stroke as is highly protocolised per the Bamford classification (a clinical diagnosis) THANKS Do you have any questions? Please leave comments in the chat or unmute Slidesgo, including icons by Flaticon, and infographics & images by Freepik.