Tpa Task 1 Case Study 25

Introduction

This case study forms part of the Stroke Course

History of Presenting Condition

Michael is a 61 year old Senior Partner in a Law Firm. While eating breakfast Michael experienced sudden onset slurring of speech, had facial droop on his left hand side with weakness in left side upper and lower limbs. Michael's wife Mary spotted these sudden onset of symptoms and immediately called for an ambulance, which arrived within 15 mins.

Past Medical History

Asthma - Dx Aged 8

Hypertension Grade 1 - Dx 5 years ago

Prediabetes - Dx 3 years ago

Medication History

Seretide Accuhaler

Ventolin (As Required - Not Required for over 1 Year)

Thiazide

Social History

61 Year Old Senior Partner at a Law Firm, recently reduced working hours 20 - 30 hours per week, previously worked 50 - 60 Hours

Planning on retirement in 1 - 2 years

Lives in a Bungalow with his wife Mary, who is a recently Retired Teacher.

2 Adult Children, both married with their own children - 1 lives close by, the other lives overseas.

Lifestyle Changes implmented over past 2 - 3 Years foloowing Dx Prediabetes.

Outside work he enjoys golf, usually playing at least 2-3 per week. Also enjoys playing Bridge with Friends.

Took up walking 3 Years ago following Dx Prediabetes. Walks 5 - 6 days per week for between 30 - 45 mins

Ex-Smoker - Hx Smoking 30 Years x 10 - 15/day - Quit 3 Years ago following Dx Prediabetes

Social Beer Drinker 10 - 15 Standard Drinks per week with 3 - 4 per session, although sometimes after Golf may be more.

Pre-Hospital Assessment

Vitals:

Physical Exam:

FAST +ve

  • Left Facial Droop
  • Left Motor Weakness: Upper Limb 0/5, Lower Limb 2/5
  • Slurred Speech 

Pre Hospital Assessment Scale:

Los Angeles Prehospital Stroke Screen (LAPSS) & Los Angeles Motor Scale (LAMS)

CriteriaYesNoUnknown

1. Age greater than 45 years 

  Yes    

2. History of Seizures or Epilepsy 

    No  

3. Onset of Neurological Symptoms is less than 24 hours 

  Yes    

4. Patient was Ambulatory prior to onset of symptoms 

  Yes    

5. Blood Glucose between 60 and 400 mg/dl

  Yes

125mg/dl


 

6. Motor Exam: Examine for Motor Asymmetry

    Based on Exam below, patient has Unilateral 'Weakness:

  Yes  
  EqualRightLeftLAMS SCORE
Facial Smile / Grimace  
Droop 1
Grip Strength  

No Grip

2
 Arm Srength  

Falls Rapidly

2
5

Acute Hospital Assessment

Vitals:

Physical Exam:

  • Confusion
  • Left Facial Droop
  • Slurred Speech 
  • Left Motor Weakness Upper Limb 0/5, Lower Limb 2/5
  • Decreased Tone
  • Altered Sensation
  • Mild Left Sided Neglect

Acute Assessment Scale:

NIH Stroke Scale: 19

Test ElementsOn Admission12 Hours post tPA24 Hours post tPA
Level Of Consciousness 1 0 0
LOC Questions 2 1 0
LOC Commands 1 1 0
Best Gaze 1 1 1
Visual Field Testing 1 1 1
Facial Palsy 2 2 1
Motor Function Arm Right 0 0 0
Motor Function Arm Left 4 3 2
Motor Function Right Leg 0 0 0
Motor Function Left Leg 2 2 1
Limb Ataxia 0 0 0
Sensory 1 1 1
Aphasia 1 1 0
Dysarthria 2 1 1
Extinction & Inattention 1 1 1
Total Score19159

Investigations

Labs:

CT:

  • Hyperdensity in the M1 Segment of the Right Middle Cerebral Artery, with no other signs suggestive of an Ischemic Stroke noted.
    Provisional diagnosis of Acute Ischemic Stroke secondary to occlusion of the M1 was made
    Patient was treated with intravenous Tissue Plasminogen Activator (tPA) at 1 h 54 min after symptom onset

MRI:

  • Multimodal MRI Scan completed at 3 h 09 min after symptom onset demonstrated Ischemic Changes confined predominantly to the Right Middle Cerebral Artery
  • Perfusion-weighted MRI showed larger perfusion abnormality, indicating presence of a substantial volume of potentially salvageable penumbral tissue.
  • Time-of-flight magnetic resonance angiography showed a loss of signal in the Right Internal Carotid Artery and Middle Cerebral Artery.

Cerebral Angiography

  • Cerebral angiogram performed post MRI demonstrated Occlusive Thrombus extending from the Right Internal Carotid Artery Origin through the Right Middle Cerebral Artery Trunk.
  • Recanalization was attempted by Endovascular Thrombectomy performed 4 h 19 min after symptom onset

Medical Management

Thrombolysis & Endovascular Mechanical Thrombectomy:

  • Discussed with Family & Patient
  • tPA Prescribed and Initiated within 1hr 54mins After Onset Symptoms
  • Endovascualr Thrombectomy Initiated at 3hr 

Stroke Unit:

  • Admitted to Acute Stroke Unit
  • 24 Hour Monitoring
  • MDT Referral Received within 24 Hours - OT, SLT & PT

Physiotherapy 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
5
3
3
2
2
3
Sphincter Control
3
3
Transfers
2
2
2
Locomotion
2
1
MOTOR SUBTOTAL SCORES 33
Communication
6
4
Social Cognition
6
4
4
COGNITIVE SUBTOTAL SCORE 24
TOTAL FIM SCORE 57

Physiotherapy Management

Ни у кого не вызовет подозрений, если ключ попадет именно к. И что особенно удачно - эту компанию меньше всего можно было заподозрить в том, что она состоит в сговоре с американским правительством. Токуген Нуматака воплощал старую Японию, его девиз - «Лучше смерть, чем бесчестье».

Он ненавидел американцев. Ненавидел американскую еду, американские нравы, но более всего ему было ненавистно то, что американцы железной хваткой держали мировой рынок компьютерных программ.

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