case study

CASE STUDY
Mr Black, a 61 year old businessman was watching the 7pm television news when he developed sudden onset of difficulty in speaking and drooping of the right side of his mouth. He was not able to lift his right arm or stand up. His wife immediately called the ambulance. The paramedics, using the FAST protocol assessed Mr Black as having had a stroke and transported him to a hospital with an acute stroke thrombolysis centre. He was admitted to the Emergency Department at 8pm.
History obtained from wife.
Mr Black was diagnosed with hypertension 10 years ago for which he takes Metopropol daily. He smokes about one packet of cigarettes/day and drinks alcohol socially. There is no history of serious illnesses or allergies. His father died of a heart attack at the age of 60.
Vital signs
BP 150/80 mmHg
Pulse 90bpm and regular
Respirations 20 breaths/minute
Temperature 36.5???? C
SaO2 95%
Neurological examination
Pupils equal – 2mm and reactive to light
Right facial droop
Paralysis of right arm and weakness of the right leg
Normal strength in the left arm and leg
Decreased sensation on right side of the body
Right knee and ankle reflexes moderately brisk compared with those on the left
Plantar response is extensor on the right and flexor on the left
Difficulty with speech – repeats yes to all questions
Laboratory tests
Full blood count – all values within normal range
Blood glucose level – 6.5 mmol/L
Electrolytes, urea and creatinine – all values within normal range
ECG – normal sinus rhythm
CT brain scan (2hours from symptom onset)
No intracranial haemorrhage or mass lesions. Suggestion of early ischaemic changes in left hemisphere.
Diagnosis
Mr Black is diagnosed with a left middle cerebral artery distribution stroke. He is assessed as being eligible for thrombolytic therapy.
Management
IV Alteplase (8.1mL bolus over minute; 72.9 mL added to 50mL sodium chloride infused over 60 minutes via a volumetric control pump).
Continue antihypertensive medication
24 hours after completion of alteplase follow-up CT brain scan – if bleeding excluded commence Assasantin???? SR capsule twice a day

PART 1 – Pathophysiology template
Complete a pathophysiology template for an ischaemic stroke that affects the dominant left cerebral hemisphere (400 words).
PART 2- Questions related to the case study
Question 1 (450 words) Explain the pathogenesis that leads to the structural and functional changes resulting from Mr Black’s stroke.
Question 2 (150 words) Explain how two of Mr Black’s clinical manifestations are related to the structural and functional changes caused by the stroke.
Question 3 (250 words) Relating your discussion to the pathogenesis of Mr Black’s condition, explain the mode of action of Alteplase and Assasantin®.

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