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You are the FY1 doctor on your A&E rotation. Please take a history from Colin Ectomy, an 89 year old gentleman who has presented with a fall. This is his second such presentation. His current medications include: Metformin Verapamil

You are an 70 year old male, called Colin. You are presenting with a 2 hour history of weakness. You are very chatty and are more interested in talking about anything other than what happened to you this morning. Make it difficult for the student: this will help them practice interrupting a patient where relevant. You can talk about; • Weather • Gardening • Your recent trip to the seaside • Your grandchildren • Your recent trip to the opticians to buy new glasses

ICE You are finding this all a bit frustrating, and just want to be able to get back to normal. You were not too worried and think it will get better like it did last time, This has happened to you once before. However, last time it only lasted 10-15 minutes. As a result, you expect it to all get better shortly, and that you will be able to go home. Your wife made you come in, as she does like to worry about you. You’re here to make her happy, as you believe that the key to a long marriage is keeping your wife happy!

PC : You fell whilst making a ham sandwich. You feel strongly that this is a huge waste of some expensive ham: it went all over the floor! You’re aslo disappointed that you didn’t get to try your tomatoes that you had picked from the garden.

HPC This morning you woke up as normal and felt well throughout the morning. You have been well previously, you can’t even remember the last time you had a cold! At lunch time (2 hours ago) you were making yourself a sandwich when your legs just gave away beneath you. You don’t know what happened, but you could not get back up off the floor. You had no headache, no aura, no dizziness, no palpitation, and no strange feelings. You remember falling to the floor and just felt a bit helpless as there was nothing you could do to stop yourself. You hit your head when you fell, you couldn’t manage to put your arm out to stop your fall.
You did not lose consciousness, and did not feel unwell, just weak. You had no incontinence or tongue biting. Your left leg and arm remain weak and you still cannot walk, or pick anything up. However, you can lift your arm up a little if asked to. Any force downwards causes it to go down again. It is the same with your left leg. Your vision was previously manageable, you just got some trendy new glasses as you are a little short sighted! However, since lunchtime you keep getting a shock when people come towards you from the side, you don’t understand why. After the fall your wife had to help prop you up against a cupboard, where you stayed until your son (‘he’s just a lovely young man don’t you know, doing really well, working as a lawyer! Can you imagine! A lawyer in my family!….’) came and got you and brought you to hospital. You felt well, just annoyed as you could not get up yourself.

PMH • The GP has said you have something funny with your heart….. It is not quite in the right time or something, but you will have to ask him about that next time you see him. • This happened once before, but got better in 10-15 mins so you would not let your son take you to hospital. That was about a month ago now. • You have diabetes and have insulin injections for this. • Your blood pressure has been high for a few years now.

DH and Allergies No known drug allergies • Meta form? for diabetes • Verapamil • Frusi iiii miiiiid ? • Maybe another one? Your wife deals with the medication….

FH • Your dad had a heart attack at 79 otherwise everyone is fit and well! You have some good genes in your family!

SH • You live with your wife, who is 69. You are both fit and well. • You manage to do everything for yourselves and do not need any help at home. • Your wife cooks wonderful food and you love your fry up every morning! • You smoke 30/day. • You drink a couple of pints of Guinness on a Friday night down the pub, and on darts nights once a month.

The student should undertake a history using the appropriate communication skills to elicit information from Colin, who is a patient who is not keen to share relevant information. Following this, a neurological examination, specifically upper or lower limb motor examination, would be appropriate.

Differential diagnosis This is likely a neurological condition, with a differential diagnosis including an acute Stroke or a Transient Ischaemic Attack. It would be relevant to consider a space occupying lesion as another neurological cause, however these do not normally present in such a way in the acute setting. This could also be a presentation of a more systemic condition. I would like to rule out hypo or hyperglycaemia, in addition to Infection or Drug toxicity; such as alcohol withdrawal.

Potential questions for discussion - Please tell me which investigations you would like to undertake for this patient. - How would you manage this patient in the acute setting? - Which intervention is associated with the greatest improvement in morbidity and mortality in strokes? - What would influence your decision to thrombolyse this patient? - Can you discuss some of the different classifications of strokes? - What is the difference between a stroke and a TIA? - Which health professionals may be involved in the long term management of a stroke patient?