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Weakness Case Study

Sample Case

Dr. Elizabeth A. is a 72 year-old retired general practitioner. 3 months ago she attended her local district general hospital Accident and Emergency department complaining of chest tightness. It was found that Elizabeth had severe unstable angina – something that came as a surprise to her as she had never experienced chest pain before. She had a history of Type II-diabetes and hypertension. She stopped smoking 20 years ago.

Elizabeth was promptly referred to the local cardiology centre where she underwent an angiogram. Elizabeth was found to have severe triple vessel coronary artery disease that was not amenable to repair by angioplasty – only a coronary artery bypass graft would save her life. Reluctantly, Elizabeth, in discussion with her husband Colin and the cardio-thoracic surgeon, agreed to undergo the procedure. Ten days after presenting with chest pain Elizabeth was scheduled to have her operation.

A few hours later, as Elizabeth awoke from the anaesthetic, it became apparent that she was unable to move her right arm or leg. She also had a right-sided facial palsy. An urgent CT scan revealed a large left middle-cerebral artery infarct. Two weeks later Elizabeth was transferred to the Stroke rehabilitation ward. Three months after attending the A&E department, Elizabeth is confined to a wheelchair, has dysarthria and dysphasia, is fed via a percutaneous gastrostomy and is incontinent of urine. Weekly multidisciplinary team meetings assess her progress.

Explain the series of clinical events that have taken place.

Consider the implications of the stroke to Elizabeth

In the short term: she is hospitalised. This will prevent her from freedom, independance, and lower her quality of life. In the long term: she is unlikely to ever fully recover from many of her physical symptoms; this will have an impact on her psychological well-being. With her new lack of mobility and independance, she is likely to quickly develop further pathology.

Common Questions

Define the different types of stroke

  • Ischaemic Stroke: clot in a brain blood vessel stops oxygen getting to a bit of brain tissue. 80% of strokes are this.
  • Intracerebral Haemorrhage: sudden rupture of a vessel in the brain, leads to blood pooling in the brain and compression brain structures. About 15% of strokes.
  • Subarachnoid Haemorrhage: haemorrhage outside the brain. The area outside the brain fills with blood, putting pressure on the brain.

Understand the relationship between the type of stroke and the physical manifestations of the event

Understand the risk factors for developing a stroke.

Know the basic acute and long-term medical management of stroke.

Be able to carry out an examination of a patient with a stroke.

Understand the limitations inherent in assessing cognition in a patient who is aphasic.

Well, its pretty much impossible to deal with aphasic patients. If someone can't talk or interpret speech, assessing cognition using standard mini mental examinations is not easy. However, the key point here is: if they don't understand anything you say, are they really capable of giving informed consent, or even comprehending any explanation of what is wrong with them?

Understand the role of the multidisciplinary team in the management of stroke.

Consider difficulties Elizabeth will have because of her incontinence.

Consider the level of care Elizabeth will require upon her discharge home.

Consider the change in circumstance for Colin who will become Elizabeth’s full time carer.

Consider the effects Elizabeth’s stroke will have upon her relationship with her husband as well as her children, grandchildren and friends.

Understand the existential implications of a stroke.

Consider the meaning of autonomy and self – determination.