An ambulance arrives and takes Iain to A&E where he is assessed by a doctor who takes his medical history.
Iain does not have any headache or sickness, his symptoms are improving but he still has some weakness in his left hand.
Category: Advancing Modules
Case 3: Iain
Scenario
Iain is a retired man aged 75. Whilst on the golf course Iain suddenly develops a weakness of his left arm, drops his club and he can’t pick it up. Fortunately he is playing golf with a retired Doctor who recognises the symptoms of stroke.
Key Messages
- If a patient is in atrial fibrillation they are ideally treated with anticoagulants
- The effects of stroke may lead to problems with medication adherence
- Reasons for non-adherence such as aphasia, visual and cognitive impairment should be fully explored
- It is important to ensure that patients have sufficient support to manage their medication
- Brief interventions are a flexible and cost effective way of addressing behaviour changes related to lifestyle risk factors after stroke
Isa’s discharge from hospital
On discharge from hospital, therapy and support will continue to address her ongoing needs. Isa has a number of follow-up appointments in her diary.
Isa’s diet
Isa has a BMI of 28 and she also has high cholesterol.
When the stroke liaison nurse talks to Isa on the ward, Isa tells her that she has a good diet as she doesn’t have a sweet tooth and never eats puddings or cakes. When asked about what she has at mealtimes, Isa then reveals that she goes to the bingo several days a week where she has the daily special. She particularly likes the ‘fish tea’ as it is only £3.00! For further information see Topic Loops below.
The liaison nurse sees this as an opportunity for a brief intervention and shows Isa the eatwell plate.
Isa had thought because it was white fish it was healthy but hadn’t accounted for the batter coating or the chips!
As a result of the brief intervention, Isa has decided she would like more information about healthy eating. She is going home tomorrow, so the liaison nurse arranges for Isa to see the dietitian when she is at the day hospital for further advice.
Topic Loops:
How would you tackle this?
Four main strategies have been devised from the feedback at the MDT meeting regarding Isa’s medication management. Go through the slides to find out more on the pie chart segments.
How will Isa cope with the changes to her medications?
The MDT meet to discuss Isa’s progress. At the meeting the issues around medication adherence arise. Go through the slides to see each of the team members response.
For further information on medication adherence see Topic Loop below.
Topic Loops:
The plan to reduce Isa’s risk of future strokes
Following the diagram below we know that:
- Isa has had an ischaemic stroke which has been confirmed by a CT scan
- Her carotid duplex showed no stenosis
- No rare causes were identified
- She has atrial fibrillation and has been initially prescribed antiplatelet drugs (aspirin 300 mg once daily). This will be changed to anticoagulant drugs in due course (normally warfarin would be started 14 days post event). See Topic Loops below for further information.
- She is prescribed cholesterol reducing drugs (simvastatin 40mg at night)
- Her blood pressure lowering drugs have been adjusted (bendroflumethiazide 2.5mg, ramipril 5mg) and she is prescribed beta blockers to control her heart rate (bisoprolol 2.5mg od)
- Her initial glucose level was raised but no changes have been made to her diabetic medication at this stage
Lifestyle behaviour changes should be used in conjunction with drug therapy to reduce the risk of recurrence
Topic loops:
Doctor McGregor’s reflections on Isa’s diagnosis
Although it seems likely that Isa’s ischaemic stroke is due to embolism from her atrial fibrillation she has mild anaemia and a raised erythrocyte sedimentation rate (ESR) which raises the possibility of rarer causes such as:
- Giant cell arteritis
- Bacterial endocarditis
- Atrial myxoma
See Topic Loops below for further information on these.
Ruling out the rarer causes of stroke:
- Dr McGregor establishes that Isa has no other symptoms or signs to suggest giant cell arteritis.
- An echocardiogram shows an enlarged left atrium but no evidence of infective endocarditis or atrial myxoma.
- Isa has a low folate which probably explains her mild anaemia with a raised mean cell volume (MCV).
- A mid stream urine specimen confirms she has a urinary tract infection which explains her high ESR which subsequently falls after treatment with trimethoprim.
Topic Loops:
Results of other tests
Isa’s electrocardiogram (ECG) confirms that she has atrial fibrillation (see ECG below). For further information see Topic Loops below.
Isa’s CT brain scan below shows a moderate sized cortical infarct in the left hemisphere.
Isa’s carotid duplex shows minor atheroma only.
