Neuroimaging of the Acute Stroke Patient - Case Study Example

Case Study Analysis - Stroke Outline Introduction 2 Background Information 2 Differential Diagnoses 3 Stroke 3 Alternative Diagnosis 6 Probable Diagnosis 8 Management Practices 8 Ambulance Response 9 Clinical Treatment 10 Care Evaluation 11 Conclusion 12 References 13 Introduction Paramedics work in an environment where it is critical to be able to recognise and correctly treat a wide range of medical conditions in complex circumstances. It is often necessary for paramedics to be able to diagnose the likely condition of an individual based on a set of symptoms that are incomplete, or that bear similarities to the symptoms of other medical conditions. The development of a correct diagnosis may be important to the survival of the patient, as the type of treatment administered varies depending on the patient’s diagnosis. The purpose of this report is to examine a case study where an elderly woman was exhibiting strange symptoms including the key clinical signs, to provide a differential diagnosis for the patient and to examine the management practices as they pertain to this particular case. Paramedics arriving on the scene were presented with information about the symptoms and behaviour of the woman around the time of the event, as well as her medical history. Background Information Alice is a 72 year old woman who lives with her husband in an apartment. At 11:30pm on a Thursday night, her husband called the ambulance because his wife was exhibiting some unusual symptoms. The first symptom was that his wife was sitting in front of the gas oven, continuously turning it on and off and saying that she needed to be there in order to keep warm. It was a humid night, so Alice’s husband was surprised that she appeared to feel cold. The second symptom was that Alice did not appear to recognize her husband, and kept mumbling to the oven rather than engaging in conversation with her husband. When the ambulance arrived, it was observed that Alice was pale and still dressed in her nightgown. Although she tried to get to her feet, she was unable to pull herself up. As such, being pale was a third symptom, while lacking motor control was a fourth. Alice’s medical history was mostly straightforward and there was little indication of any major aspects that would have an influence on the symptoms that she was showing. Alice is retired, but remains active in the community by being involved in volunteer groups and acting as a teacher for children within the area. She has not had any significant health complications, aside from breaking her leg several years ago in a car accident. She has no history of falls and her husband considers her to be in good health. She is not currently on any medication. Differential Diagnoses Stroke As is the case with many people, diagnosis is difficult, because there are a range of different symptoms that do not easily fit into recognised categories. One potential diagnosis for Alice is a stroke. Strokes play a significant problem for healthcare, with an estimated prevalence of between 100 and 300 per 100,000 people in industrialised countries (Britton et al., 1985). Stroke is a prominent emergency situation, where the patient requires immediate medical evaluation and care. In the case of a stroke, the amount of time taken to seek and receive medical treatment has a substantial impact on survival and recovery. A stroke can lead to death or significant restrictions on bodily functions; although in some cases people can make a complete recovery. A full recovery from a stroke relies on people obtaining treatment quickly (Gonzalez et al., 2011), which is in turn dependant on their symptoms being recognised by those around them and by emergency staff. There are a range of symptoms that people with a stroke can exhibit, including some that are common and others that are atypical. Speech problems and motor deficits are two of the most frequently reported symptoms of stroke, while symptoms such as issues with sensation, and vertigo are not often mentioned although they are also symptoms of a stroke. The symptoms of a stroke occur throughout the body, because the stroke acts to damage the brain. One of the most visible impacts of a stroke is motor activity, and because of this strokes are often recognised by the patient falling. Paralysis of part of the body or numbness on one side of the body are also common and well-recognised symptoms (Handschu et al., 2003). A stroke can occur to anybody regardless of age or medical condition. Worldwide, strokes are responsible for around nine percent of the deaths that occur each year (The University Hospital, 2012). There are many preventable risk factors for stoke, including smoking and high blood pressure (Asplund et al., 2009), however, Alice’s lifestyle and habits did not have any of these prominent avoidable risk factors. While anyone can have a stroke, the risk significantly increases with age. For each decade over 55, the risk of stroke approximately doubles (The University Hospital, 2012). As such, despite the fact that Alice has no current or prior illnesses that can act as a risk factor for stroke, her age is still a significant risk factor. Alice’s symptoms match up with those of a stroke in the following ways. Firstly, motor deficits are one of the most commonly reported symptom of a stroke (Handschu et al., 2003), and this symptom was observed in Alice by the fact that she was unable to get up from her chair when the ambulance arrived. Another significant symptom associated with stroke is having a problem with sensation (Handschu et al., 2003). This could relate to Alice’s perception of temperature, was she appeared to be unable to properly differentiate between warmth and cold, believing that she needed to by near the gas oven to be warm even though the air temperature was already humid. Speech problems also occur as part of a stroke (Handschu et al., 2003), and this could explain the way that Alice appeared to be mumbling to the oven. These symptoms are common in a person who has had a stroke. While the inability to recognise her husband is not a symptom of a stroke, it is possible that this could be influenced by other factors. For example, the reported symptom was that she did not appear to recognise him, and continued mumbling to the oven. If she was having speech difficulties, which could have arisen from a stroke, then it is possible that she was trying to communicate with him, but it did not appear so to the husband. Additionally, a stroke can lead to changes in the survivor’s vision and perception. Such changes can include decreased awareness of one side or loss of vision in some areas (Memorial Medical Center, 2012b). As such, Alice’s lack of recognition for her husband could be based on the fact that she could not see him properly, and had limited perception of his presence. In addition, confusion can also occur as the result of a stroke, which could help explain Alice’s behaviour towards the oven and her husband, and her apparent lack of awareness of what was going on around her (Memorial Medical Center, 2012a). Alternative Diagnosis However, not all symptoms that Alice showed could have been caused by a stroke. In particular, she was noticed by emergency responders as being pale, which is not a symptom of having a stroke. Additionally, not recognising her husband is also not a symptom that is commonly associated with a stroke. One potential mechanism for this was discussed above; however, it may also indicate that there is another medical explanation from what happened to Alice. The diagnosis of a stroke is often difficult, because there are many different clinical conditions that present with similar symptoms. Some of these include dementia, intracranial haemorrhage, seizure or complicated migraine (Copen and Lev, 2007). In the case of Alice, the presence of symptoms that are not directly related to a stroke suggests an alternative medical explanation rather than a stroke or a condition which resembles a stroke. The most prominent aspect which suggests an alternative diagnosis is the fact that she was pale, and that her behaviour suggested that she was cold. Based on this information, one alternative diagnosis is hypothermia. Hypothermia is a state where the mechanism for temperature regulation within the body of the individual is overwhelmed from exposure to significant cold. In some cases, hypothermia can occur from an illness that decreases the temperature within the body. The elderly are at increased risk for hypothermia, and can sometimes present with symptoms that are not immediately associated with hypothermia, such as an altered mental state. In patients that primarily life indoors hypothermia can be caused by less extreme cold, and the history may be more difficult to pinpoint. If the hypothermia is mild or moderate, symptoms can include dizziness, chills and confusion (Edelstein, 2011). Alice’s symptoms matched those of hypothermia in a number of ways. Firstly, her apparent disorientation and inability to recognise her husband could be the result of dizziness and confusion respectively. The confusion could also have led to Alice mumbling at the oven. Her focus on obtaining heat from the oven and the paleness of her skin could have been an indication that she was cold. However, despite this, there are several factors that suggest that hypothermia was not the most likely diagnosis for Alice. Firstly, the day in which the event occurred at was warm, and Alice’s husband did not mention any incidents where Alice was exposed to a sufficient amount of cold to result in this outcome. His statement suggested that the day was ordinary in all respects, which suggests that it was not an external event that triggered her symptoms. Secondly, while some of Alice’s symptoms matched hypothermia, she did not have many of the major symptoms of the condition. For example, if she had mild hypothermia, she would have been showing symptoms such as substantial shivering and an increase in respiratory rate (Edelstein, 2011). These symptoms were not observed in Alice. Probable Diagnosis Based on the differential diagnoses discussed above, the most likely diagnosis for Alice is that of a stroke. Although stroke is considered to be an ancient disease it has become a major health problem in recent years and the subject of a substantial amount of research. However, despite the prevalence of research and attention on stroke and the causes of this medical emergency, treatment for stroke patients remains suboptimal (Selim, 2007). Management Practices The management of acute strokes has continued to develop, with new therapeutic strategies providing methods of evaluation and treatment. One critical aspect of this is the fact that some stroke treatments can only administered within a certain time period after the stroke has occurred. Because of this, it is crucial that ambulance staff are able to recognise the symptoms of stroke when they occur (Handschu et al., 2003). It is recognised that there is only a narrow window in which to act after a person has had a stroke , and the faster that interventions can be implemented, the more chance the person has of making a full recovery (Selim, 2007). Emergency care of people with a stroke is compounded by whether the symptoms are recognised as being that of a stroke by the dispatcher or through the information that the caller provides (Handschu et al., 2003). The diagnosis and management of a stroke is also difficult because there are no effective diagnosis assays that can quickly be used in an emergency setting (Reynolds et al., 2003). This means that frequently strokes must be determined based on medical history and symptoms. As is the case in the case study being discussed in this report, the symptoms that emergency staff are presented with can be unclear and difficult to interpret. This limits how effectively strokes can be diagnosed, and the correct treatment assigned. Ambulance Response The diagnosis, or probable diagnosis, of a stroke is significant from the perspective of the ambulance officers, and indicates the need for important behaviour on their part. As discussed previously, there is only a limited amount of time available to treat patients with a stroke, and the sooner treatment is begun, the more effective it is likely to be. Because of this, the ambulance officers should attempt to spend as little time as possible at the scene, and to get the patient on the way to the hospital as quickly as possible. If the patient is incoherent, as was the case with Alice, it is important to obtain a timeline of the events that happened if possible, in this case, the information was provided by Alice’s husband. It is also important that the psychological state of the patient is taken into account. A stroke is a frightening event, and the patient may have no idea what is happening to them or why it is occurring. Ambulance staff should attempt to reassure the patient wherever possible. When ambulance staff are dealing with someone who has a probable or even possible stroke, it is critical that they are taken to the hospital as soon as possible, and that the hospital is adequately informed that the patient might have suffered a stroke. Studies have shown that people arrive to a hospital in an ambulance after suffering a probable stroke were around twice as likely to obtain a scan within the recommended time frame. It was also indicated that if the ambulance notified the hospital in advance that they were bringing a probable stroke victim, this increased to three times as likely (Schultz, 2011). Clinical Treatment Once patients who have suffered from a stroke are in hospital they are able to be treated for the stroke. One such treatment is thrombolytic therapy, which needs to be administered within six hours of the stroke occurring. This treatment is used for ischemic stroke, which is the most common type of stroke, which occurs when the flow of blood to the brain is compromised, resulting in cell death (Gonzalez et al., 2011). However, the treatment for a stroke is strongly dependant on the type of stroke, which is why there is a significant need to confirm the stroke diagnosis and determine the type of stroke prior to any treatment (Roberts, 2012). The first aspect of treatment for a stroke involves confirming the diagnosis of stroke. This is generally achieved through imaging technologies, such as magnetic resonance imaging (MRI) and computed tomography (CT) scans. To confirm the diagnosis of a stroke, scans are used to rule out alternative diagnoses such as haemorrhage. In some cases, the imaging may also be able to provide additional information about the brain tissue, which can help to guide therapy for the stroke, by indicating which regions of the brain may be salvageable and which are not (Copen and Lev, 2007). If the stroke occurred because of a blood clot (ischemic stroke), which happens in around 80% of strokes, then drugs to break up the clot are used. However, this form of treatment cannot be used if the stroke was caused by a bleed, rather than a clot (Roberts, 2012). Because of this, confirming that a stroke has occurred, and determining what type of stroke it was is a critical and highly time-sensitive aspect of clinical treatment. Care Evaluation The care available for patients who have suffered from a stroke remains inadequate despite the prevalence of research into this area. In the case of Alice, an initial assessment of a stroke should have been made at her location. She should then have been transferred to an ambulance quickly, and taken to the nearest hospital. The ambulance staff should have made efforts to reassure her, and most critically, should inform the hospital that they were bringing in a probable stroke patient. Once she reached the hospital, Alice should then have received the necessary scans and treatment based on the type of stroke she had, or her medical condition. In this case, it is critical that a stroke is assumed until tests prove otherwise, because time is a significant factor when dealing with a person who has had a stroke. If this diagnosis is incorrect, a correct diagnosis would be made at the hospital after tests had been run. One of the biggest problems with the care that is available to stroke victims is the amount of steps that are required for the patient to receive the care they need. It is often suggested that there is approximately a three-hour window between when the patient suffers a stroke and when treatment is administered, if treatment is given after this point, it is likely to be ineffective (LaMonte et al., 2004). Hospital guidelines suggest that brain scans should occur no later than 25 minutes after arriving in the hospital, and interpretation of the results should happen within 20 minutes of the scan, however, with hospital time limitations, this often does not occur (Schultz, 2011). Studies have also shown that many ambulance crews are not letting hospitals know that they have a patient who may have had a stroke (McDermid, 2012). A recommendation that has been developed in some studies is the use of mobile stroke technology to dramatically decrease the treatment times for stroke. This approach has been used within a German study to lower the time between emergency call and treatment from 76 minutes down to 35 minutes. This was achieved by equipping ambulances with mobile technology, including a point-of-care laboratory and a mobile CT scanner (Skilton, 2012). This approach to treatment would significantly reduce the chance of damage as the result of stroke, and increase effective and timely treatment. Conclusion This report shows that the symptoms that Alice presented with were most likely the result of a stroke. This indicates an urgent need for medical attention, and that time is a significant aspect of how effective the treatment for Alice will be. The ambulance officers need to minimise the time spent at the scene and in the ambulance to ensure that Alice receives the best and most prompt care possible. In addition, the ambulance staff needs to inform the hospital of Alice’s condition prior to her arrival, to increase the chance of her receiving scans and treatment in time. Currently, the approach to the treatment of strokes is lacking, and patients often do not receive treatment in enough time. One possible approach is that undertaken by a German study, which made use of technology within ambulances to provide testing capabilities, which decreased the time taken to test and provide treatment to a person dramatically. References Asplund, K., Karavanen, J., Giampaoli, S., Jousilahti, P., Niemela, M., Broda, G., Cesana, G., Dallongeville, J., Ducimetriere, P., Evans, A., Ferrieres, J., Haas, B., Jorgensen, T., Tamosiunas, A., Vanuzzo, D., Wiklund, P.-G., Yarnell, J. & Kuulasmaa, K. 2009. Relative risks for stroke by age, sex, and population based on follow-up of 18 European populations in the MORGAM project. Stroke, 40, 2319-2326. Britton, M., Jonsson, E., Marke, L.-A. & Murray, V. 1985. Diagnosing suspected stroke: A cost-effectiveness analysis. International Journal of Technology Assessment in Health Care, 1, 147-158. Copen, W. A. & Lev, M. H. 2007. 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