Acute weakness-In-patient stroke

A 70 year old patient has been admitted to the medical ward with a right leg cellulitis. He is known to have poorly controlled T2DM, Hypertension and Heart failure with reduced ejection fraction. You are asked to review the patient on the ward as he is more confused since the last hour or so. Please assess this patient and talk us through how you would approach this new complaint.

Answer- The expectation is that the candidate should go through a brief history with the nursing staff regarding when he was seen well prior to this. The candidate will need to go through the history in a systematic manner – confirming what was done for the patient this admission, his past medical history, his functional baseline and proceed to examination. The examination would need to be in a systematic manner using the A to E approach. The candidates would need to ideally go through each and every step of the approach until the interviewer interrupts.

Airway- Patent

Breathing- spontaneous respiratory effort, RR- 16/ minute, SpO2-98% on air, chest examination- Unremarkable

Circulation- BP- 190/80 mmhg, HR- 80 bpm, Pulse- Irregularly irregular , HS – irregular with no added murmurs, If an ECG is requested the interviewer will give it afterwards

D- GCS-E4V4M6, on being told by the candidate that a focused neurological examination would be done give the following findings to the candidate. Here’s the ECG (It would show Atrial Fibrillation). The neurological examination would be presence of a left gaze deviation, the patient seems to not be answering the questions appropriately and has impaired comprehension and poor speech output. There is a subtle right facial palsy and moderate right sided pyramidal weakness of his arm and leg.

Given these findings the candidate would be expected to put a stroke alert to the ward and handover to the stroke team.

The interviewer may ask the following depending on the time available. If the stroke team are concurrently managing another patient what would your next steps be?

The expectation is that the candidate would arrange an urgent CT scan with or without angiogram depending on the local policy and discuss the patient with the stroke consultant regarding acute therapies such as IV thrombolysis and Endovascular thrombectomy. The candidate is expected to know the indications for IV thrombolysis here. The handover to the stroke team or the consultant should ideally be as below using a SBAR approach:

‘ I was asked to see this 70 year old gentleman admitted with poorly controlled T2DM, HTN and CHF admitted with a right leg cellulitis who became more confused over the last hour or so. He was last seen well 60 minutes back. On examination he had evidence of a right sided pyramidal weakness of his face, arms and legs along with a left gaze deviation and he had a new AF on his ECG. I have arranged an urgent CT head and angiogram for him. He has a good functional baseline and lives by himself and doesn’t need any support to ambulate. I think he may be a candidate for acute treatments depending on the CT scan. I was wondering if your team would be happy to assess him and start treatments if appropriate.’