Practice this case based on how you are assessed in your OSCEs, and use the relevant sections for general revision. 🤓
Doctor Instruction:
You are a Foundation Doctor working in the Emergency Department. Your next patient is Charlie Brown, a 63-year-old man presenting with problems with speech. Please take a history and carry out a relevant examination.
Patient History:
Charlie Brown, 63y/o M, Engineer.
Your partner noticed a few hours ago that you were difficult to understand while speaking during dinner. Your speech has been slurred, according to your partner, and it happened very suddenly. Your partner was really worried about this and therefore called an ambulance.
You have noticed you cannot see things on your left which is “kinda weird” – you have never experienced this before in the past – you have to constantly rotate your neck to the side to see more. You also feel tired and not “really yourself”. You noticed you could not pick up your fork with your left hand or lift your left leg up when you tried to walk. These symptoms have not settled since then.
You are unsure whether you have swallowing difficulties, but you ate fine before slurred speech kicked in. No dizziness/ unsteadiness/ numbness/ headache/ confusion/ loss of consciousness/fever.
Ideas, Concerns, Expectations:
You think this might be another "ministroke". You had this last year which quickly resolved. You think you are likely to get better because of this. You have no concerns – you don't know why your partner was so concerned about this. You just want to go home and don't want to miss out on watching your favourite TV show.
Past Medical History:
Hypertension, atrial fibrillation, obesity, hypercholesteremia, previous “ministroke” x1 last year. Had a hernia operation in 2014.
Drug History:
Atorvastatin, aspirin, amlodipine, ramipril, apixaban.
NDKA
Family History:
Father had a heart attack when he was 50
Social History:
You live with your partner in a semi-detached house.
You work as an engineer.
You smoke 10 cigarettes a day since when you were a teenager (can't remember for how long exactly).
you drink a pint of beer every weekend.
Examination Findings:
Slurred speech
Left-sided weakness for arm and leg
Left homonymous hemianopia
No higher cerebral dysfunction (dysphasia, visuospatial disorder)
Differentials:
Stroke – likely ischaemic PACS ( Ischaemic stroke (87%) vs Haemorrhagic stroke (13%) )
Stroke – other forms
TIA
Investigations:
Observations + neuro observations
ECG / Echo – to rule out cardiac cause
Bloods: glucose (exclude hypoglycaemia), U&Es (neurological signs + exclude renal failure), FBC (r/o anaemia or infection), coagulation screen with INR
USS doppler carotids – rule out aortic stenosis
Non-contrast CT Scan (immediate) – to determine management: ischaemia vs haemorrhage
For further investigations: MRI Scan/CTA/MRA
Management: