Amelia Frankish is 67 years old. She presented to her GP last week, complaining of a very strong headache, followed by dizziness. The symptoms had resolved by the time she could see the GP, who was concerned enough to request a CT (computerised tomography) of Amelia's head and neck. medical history: Diabetes mellitus Type 2: Management: metformin 1000mg, daily enalapril 10 mg daily rosuvastatin 10mg, daily Atrial fibrillation (AF) Management: apixaban 2.5 mg, BD sotalol 40 mg, BD Cigarette smoking: 20 - 30 cigarettes/day, quit 5 years ago.  GP diagnosis - one week ago. Amelia underwent a CT scan of the head and neck, but the results were normal. Amelia was assessed as requiring changes to her hypertension & AF management and the following changes made: enalapril ceased the following medications commenced or changed; irbesartan/ hydrochlorothiazide 300/25, daily amlodipine 5mg, daily apixaban 5mg, BD. Today: Amelia woke early this morning at 0600 hours with a 5/10 headache. At 0700 hours she began to feel weak in her limbs, and her headache increased to 7/10. One side of her face began to "feel strange". She was able to call her neighbour, who brought her to hospital. Triage: Time is now  0800.   Vital signs:   RR: 18 bpm   SpO2: 98%   BP: 180/92 mmHg  (MAP 121 mmHg) HR: 98 bpm   Temp: 37oC     Pain assessment:   Provoking/palliating: pain is worse when Joyce moves her head suddenly, nothing seems to relieve the pain   Quality: the pain feels like extreme pressure on the left side of her head   Region/radiation: the pain is confined to her head   Severity: 9/10   Timing: first pain onset was about 2 hours ago     Neurological assessment:   GCS: 15   Pupils: PERRLA   ROSIER (Recognition of stroke in the emergency room) Scale Loss of consciousness or syncope: NO Seizure activity: NO Asymmetric facial weakness: YES Asymmetric arm weakness: YES (right upper limb paralysis - unable to respond to movement request) Asymmetric leg weakness: YES (right lower limb paresis – mild weakness)  Speech disturbance: YES (some slurring of words (dysarthria) is noted) Visual field deficit: NO Other: Limb sensation: right upper limb anaesthesia; right lower limb - paraesthesia (tingling feeling).   Amelia appears pale and anxious. She has not had her medications today. Investigation data after Triage: Cardiovascular assessment   An ElectroCardioGram (ECG) is undertaken which shows normal sinus rhythm.      Blood tests are ordered including full blood count (FBC), urea & electrolytes (U&Es), liver function tests (LFTs), coagulation studies (COAGs) including Anti-Xa levels.   Metabolic assessment  Blood Glucose Level (BGL): peripheral 9.8 mmol/L (Amelia reports not having eaten since yesterday, nor has she had her medications today)     Computerised Tomography report Exam Information Modality: CT Body Part: NEURO Description: CT Brain  Performed Date: 25/3/Year Time: 0830 Final Report CT BRAIN  CLINICAL NOTES: Patient presents with severe headache, dysarthria, limb anaesthesia, paresis, and paralysis. CT 7 days ago - no adverse findings Findings: A non- contrast CT has been acquired. Nil intracranial haemorrhage noted. Complete occlusion of the left middle cerebral artery noted. IMPRESSION: Middle cerebral artery thrombosis (not conclusive). Question: Take Action   "1/24 (hourly) neurological assessment for 4 hours" has been requested for Amelia.   Referring only to the limb movement component of the assessment, provide a rationale for this intervention by:   referring to relevant anatomical structures and discussing the pathophysiological mechanisms of deterioration that would cause observed changes to Amelia's limb movement assessment,   identifying TWO other assessment data (signs or symptoms) that might be evidence of neurological deterioration, and   identifying the guidelines that support this intervention of hourly neurological assessment.   Word limit: 200 words

Amelia Frankish is 67 years old.

She presented to her GP last week, complaining of a very strong headache, followed by dizziness. The symptoms had resolved by the time she could see the GP, who was concerned enough to request a CT (computerised tomography) of Amelia's head and neck.

medical history:

Diabetes mellitus Type 2:

Management:

• metformin 1000mg, daily
• enalapril 10 mg daily
• rosuvastatin 10mg, daily

Atrial fibrillation (AF)

Management:

• apixaban 2.5 mg, BD
• sotalol 40 mg, BD

Cigarette smoking: 20 - 30 cigarettes/day, quit 5 years ago. 

GP diagnosis - one week ago.

Amelia underwent a CT scan of the head and neck, but the results were normal.

Amelia was assessed as requiring changes to her hypertension & AF management and the following changes made:

• enalapril ceased

the following medications commenced or changed;

• irbesartan/ hydrochlorothiazide 300/25, daily
• amlodipine 5mg, daily
• apixaban 5mg, BD.

Today:

Amelia woke early this morning at 0600 hours with a 5/10 headache. At 0700 hours she began to feel weak in her limbs, and her headache increased to 7/10. One side of her face began to "feel strange". She was able to call her neighbour, who brought her to hospital.

Triage:

Time is now  0800.  

Vital signs:  

• RR: 18 bpm  
• SpO2: 98%  
• BP: 180/92 mmHg  (MAP 121 mmHg)
• HR: 98 bpm  
• Temp: 37^oC  

Pain assessment:  

• Provoking/palliating: pain is worse when Joyce moves her head suddenly, nothing seems to relieve the pain  
• Quality: the pain feels like extreme pressure on the left side of her head  
• Region/radiation: the pain is confined to her head  
• Severity: 9/10  
• Timing: first pain onset was about 2 hours ago  

Neurological assessment:  

• GCS: 15  
• Pupils: PERRLA  

ROSIER (Recognition of stroke in the emergency room) Scale

• Loss of consciousness or syncope: NO
• Seizure activity: NO
• Asymmetric facial weakness: YES
• Asymmetric arm weakness: YES (right upper limb paralysis - unable to respond to movement request)
• Asymmetric leg weakness: YES (right lower limb paresis – mild weakness) 
• Speech disturbance: YES (some slurring of words (dysarthria) is noted)
• Visual field deficit: NO

Other:

Limb sensation: right upper limb anaesthesia; right lower limb - paraesthesia (tingling feeling).  

Amelia appears pale and anxious.

She has not had her medications today.

Investigation data after Triage:

Cardiovascular assessment  

An ElectroCardioGram (ECG) is undertaken which shows normal sinus rhythm.     

Blood tests are ordered including full blood count (FBC), urea & electrolytes (U&Es), liver function tests (LFTs), coagulation studies (COAGs) including Anti-Xa levels.

Metabolic assessment 

Blood Glucose Level (BGL): peripheral 9.8 mmol/L (Amelia reports not having eaten since yesterday, nor has she had her medications today)  

Computerised Tomography report

Exam Information
Modality: CT
Body Part: NEURO
Description: CT Brain 
Performed Date: 25/3/Year Time: 0830
Final Report
CT BRAIN 
CLINICAL NOTES:
Patient presents with severe headache, dysarthria, limb anaesthesia, paresis, and paralysis. CT 7 days ago - no adverse findings

Findings:
A non- contrast CT has been acquired.
Nil intracranial haemorrhage noted.

Complete occlusion of the left middle cerebral artery noted.

IMPRESSION:
Middle cerebral artery thrombosis (not conclusive).

Question:

Take Action  

"1/24 (hourly) neurological assessment for 4 hours" has been requested for Amelia.  

Referring only to the limb movement component of the assessment, provide a rationale for this intervention by:  

• referring to relevant anatomical structures and discussing the pathophysiological mechanisms of deterioration that would cause observed changes to Amelia's limb movement assessment,  

• identifying TWO other assessment data (signs or symptoms) that might be evidence of neurological deterioration, and  
• identifying the guidelines that support this intervention of hourly neurological assessment.  

Word limit: 200 words