Summary of history:
A 70-year-old1 woman named Mrs. Nelson2 has a stroke. She is a widow. It turns out to be a fairly classic ischemic stroke in the left middle cerebral artery territory, resulting in aphasia and right hemiparesis, but it is still a challenge to figure out if she can manage at home.
1The age isn't critical to be 70, but should be somewhere in the vicinity.
2The name was pulled somewhat at random. Could be changed to fit a different cultural background.
Summary of questions for learners to address:
- How is status from stroke assessed using standardized evaluations?
- How does interprofessional team contribute to assessing a stroke survivor's status and potential to benefit from a stroke rehabilitation program? What are indicators that point to likely outcome from stroke?
- How do team members interact with a person who has potentially intact intellect other than impaired language (both comprehension and expression in both written and spoken language)?
- What is the significance of neuroplasticity for early care by the entire team after stroke? What is the evidence for coordinated care by stroke teams?
- Even after an excellent outcome from inpatient rehabilitation, what are discharge challenges for an elderly person previously living alone to go home with some stroke-related disability?
Overall timeline & potential learning objectives at each point:
Time point #1: A 70-year-old woman is admitted through Emergency with signs of ischemic stroke. She was found by neighbours and itif unclear how long since onset of stroke signs & symptoms.
- Potential key questions related to learning objectives (principally for medical students?):what is time window for TPA? What decision tree for whether she is candidate for TPA? What are other diagnostic tests for work-up to definite diagnosis of stroke?
Time point #2: Mrs. Nelson was definitely diagnosed with ischemic stroke of the left middle cerebral artery (could specify branches if we wished?). She has global aphasia and left hemiparesis. It has been a short time (a few days? a week? 10 - 14 days?) since her admission. [Specify her score on a number of scales that are standard for evaluating stroke: Canadian Stroke Scale? (need to check with MDs) Clinical Outcome Variable Scale (COVS), Chedoke-McMaster Stroke Assessment (CMSA) impairment inventory, Fugl-Meyer Assessment of Stroke, Stroke Rehabilitation Assessment of Movement (STREAM) - it would be unrealistic to use all of these scales because of overlapping information, but could figure out which of them in combination yield a composite profile.] All of communication and mental status exams need to be adapted to reflect her language impairment. Aphasis is "global" in the sense of expression and comprehension both being impaired, but neither is totally impaired. All of Mrs. Nelson's scores indicate that she is "middle band" of stroke impairment (where upper band are so little impaired they go straight home, middle band go to rehabilitation, and lower band go to long-term care, roughly speaking).
- Potential key learning objectives: to become skilled at interpreting scores from standardized evaluation of post-stroke impairment; to identify variables that are used to determine an acute stroke survivor's suitability for referal to rehabilitation; to describe what is (should be?) done for acute stroke patients in the acute and subacute phase to maximize recovery due to neuroplasticity; to become skilled at strategies for communication with a patient with presumed intact cognition but impaired expression and comprehension of written and spoken language; to describe roles of interprofessional team members in assessing potential for recovery and therefore referral, and to maximize recovery
Time point#3: Mrs. Nelson is coming to the end of a 4-week stay at an inpatient rehabilitation program for stroke patients. She has improved tremendously in all aspects of her stroke impairment [need new scores for the scales measured at Time point #3]. Her FIM score has gone from 62/126 to 113/126 (possibly an unrealistically big improvment). She has been able to be measured on Berg Balance scale (now 44/56, could show breakdown?) and Timed-Up-and-Go (TUG), (15 seconds). Her communication ability has improved - still impaired but able to get her ideas across and able to understand, as long as given extra time (and with technology? need to check with Speech-language pathologist?)
- Potential key learning objectives: to develop further skill at interpreting scores from standardized evaluation of post-stroke impairment and to understand how they capture recovery from stroke; to develop further ability to describe what is (should be?) done for acute stroke patients in the rehabilitation phase to maximize recovery doe to neuroplasticity; to identify issues to consider in discharge home in a case of significant ongoing disability
[Time point #4: could do a home care scenario?]
If you would like to help develop this case Interprofessionally, please contact Kathleen Norman.