Geriatric osce: Stroke Assessment



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Geriatric OSCE: Stroke Assessment


General assessment:




  • Assess the patient, their state, any aids / equipment etc.




  • Motor function, standing / sitting / lying




  • Facial appearance, speech










Examination:




  • Facial movements:

    • Raise eyebrows

    • Scrunch eyes

    • Puff out cheeks and hold them out

    • Open mouth, and against resistance

    • Tongue in / out / left / right




  • Facial sensation:

    • Ocular / maxillary / mandibular branches

    • Tongue




  • Ocular:

    • PLR’s

    • Movements: Double-H

    • Visual fields: seeing, and when movement stops




  • Upper limbs:

    • Tone

    • Gross motor

    • Sensation

    • Reflexes: including grasping




  • Lower limbs:

    • Tone

    • Gross motor

    • Sensation

    • Reflexes: including Babinski




  • Speech:

    • Orientation in time / place / person

    • General use of words:

    • Stating names and purposes of finger / pen / watch, name things starting with F

    • Identify their ownership of left / right hands

      • Hemi-neglect




  • Actions:

    • Act as if you’re brushing your teeth

      • Dyspraxia if can’t carry out actions

    • Draw a clock

      • May detect hemi-neglect, impaired executive function,

    • Simple maths: 2+6 = 8

    • Write their name

      • May detect agraphia or dyspraxia















Interpretation:




  • Dominant (Left) MCA lesion:

    • Right weakness / impaired sensation

    • Aphasia – Wernicke’s or Broca’s

    • Dysarthria – distinguish from cerebellar speech

    • Right visual field deficit

    • Impaired reading / writing / calculating (acalculia, agraphia)




  • Non-dominant (Right) MCA lesion:

    • Left weakness / impaired sensation

    • Spatial disorientation

    • Left visual field deficit

    • Dysarthria (distinguish from cerebellar speech)




  • Brainstem lesion:

    • 4-limb weakness and sensory impairment

    • Ataxia

    • Nystagmus

    • Bilateral visual field deficits







  • Lateral Medullary Syndrome:

    • Ipsilateral numbness, limb ataxia, Horner’s Syndrome, pain over eye

    • Contralateral loss of sensation (pin prick and hot-cold)

    • Vertigo, nausea, hoarseness, hiccups, dysphagia















Questions:




  • Treatment for acute stroke:

    • Rule out intracranial haemorrhage first

    • Thrombolysis if less than 4hrs (exact timeframe of who benefits at what time is still unclear)

    • Rehabilitation: rehabilitation physician, physiotherapy, speech and occupational therapy




  • Outcomes of stroke:

    • Majority of recovery occurs within first 3 months, minimal neuro improvement past 6 months

    • At 1 yr: 1/3 die, 1/3 permanently impaired, 1/3 minimally or no residual impairment

    • High rate of post-stroke depression




  • Secondary prevention:

    • Anticoagulation (aspirin / clopidogrel / other antiplatelets, NOAC’s, warfarin)

    • Lipid, diabetes, HTN control

    • Carotid endarterectomy




  • CT findings:

    • Haemorrhagic stroke:

      • Hyperdense diffuse region of haemorrhage

      • Mass effect, increased intracranial pressure, herniation / displacement

    • Ischaemic stroke:




  • MRI findings:

    • Haemorrhagic stroke:



      • Poor for detection of subarachnoid haemorrhage

    • Ischaemic stroke:

      • Loss of grey-white distinction

      • Loss of clarity of basal ganglia




  • Differentials:

    • Thromboembolic stroke

    • Haemorrhagic stroke

    • Mass lesion (+/- acute necrosis / haemorrhage within mass)

    • Hypoglycaemia

    • Electrolyte abnormalities, esp hyponatraemia +/- overly rapid correction

    • Delirium











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