Article Text
PDF
Statistics from Altmetric.com
Registrar: ‘Hello, am I speaking with the consultant neurologist on-call?’
Consultant: ‘Regrettably! Yes that’s me. What is it?’
R: ‘Hi this is Dr Richter, medical reg. on call. Sorry to disturb you so late, but we’ve got a FAST1 positive in A&E.’
C: ‘A what?’
R: ‘A FAST-positive patient.’
C: ‘I assume that’s worse than a FAST-negative patient then. Go on.’
R: ‘Well the NIHSS2 is 24 but her GCS3 4 is 12 currently. Before we got the CT, I was worried about a subarachnoid, because her Hunt & Hess5 was 4.’
C: ‘Gosh.’
R: ‘But thankfully the CT showed no bleed, but the ASPECTS6 was 6.’
C: ‘Six, did you say? That doesn’t sound too bad. At least it’s not 10 or something.’
R: ‘Actually 10 is a normal score. You really don’t want an ASPECTS lower than 6.’
C: ‘I see. So what are you recommending to do?’
R: ‘Well, time is brain, Professor, and I think it would be good to keep our door-to-needle stats under 45 min, so I think we should push on with the tPa. Also the nurses are concerned that her NEWS27 is now 7.’
C: ‘I suppose that is not good news then.’
R: ‘Actually it is a fully validated score with a high positive predictive value. It is now a fully integrated component of the patient journey documentation protocol.’
C: ‘Hold on a second; do we have any idea what her usual state of health is like?’
R: ‘Well Prof, I was flicking through the chart. In fact I see from the medical notes that her CHA2DS2-VASc8 score was 4 at her last outpatient visit.’
C: ‘Chadsvasck? Sounds like a tropical disease.’
R: ‘There’s more. She definitely has dementia; her MMSE9 was only 22 at that outpatient visit, and they recommended a consultation with the Frailty Team.’
C: ‘The Frailty Team? Is there a Frailty Team?’
R: ‘Oh yes Prof. In fact I would estimate the patient has a clinical frailty scale10 score of around 6.’
C: ‘That doesn’t sound good .’
R: ‘You’re right, it isn’t. But I reckon if we get going with the tPa, maybe she might be lucky and come out of this with a modified Rankin11 of 3 at three months.’
C: ‘I see. Is she systemically unwell?’
R: ‘Actually her chest X ray shows some possible focal consolidation, but fortunately her CURB6512 score is only 2, so we are in good shape on that front.’
C: ‘Look, I’m getting confused with all these acronyms and scales and stuff, can you just summarise the relevant clinical details in a sentence.’
R: ‘Sure Prof, no problem. So we have a FAST-positive lady with an NIHSS of 24, GCS 12, negative CT with ASPECTS of 6 with a background CHA2DS2-VASc of 4, MMSE 22, frailty score of 6 and a rising NEWS2, currently at 7.’
C: ‘Are you trying to tell me this woman is having a stroke, Dr Richter?’
R: ‘Em, in a word Prof, yes.’
Glossary
FAST (1): Face drooping, Arm weakness, Speech difficulty, Time to call emergency services. Developed as part of an initiative to increase public awareness of acute stroke symptoms.
NIHSS (2): National Institutes of Health Stroke Scale. An 11-item scale used to quantify the degree of disability in acute stroke. A higher score indicates increasing disability (maximum 42).
GCS (3 and 4): Glasgow Coma Scale. A 15-point scale to describe a patient’s level of consciousness. A lower score (minimum 3) indicates increased impairment.
Hunt & Hess Scale (5): A scale (1–5) used to describe the clinical severity of subarachnoid haemorrhage, a higher score indicating increased impairment.
ASPECTS (6): Alberta Stroke Program Early CT Score is a 10-point topographic CT score used in patients with middle cerebral artery stroke. A lower score indicates increasing middle cerebral artery territory involvement.
tPa: tissue plasminogen activator.
NEWS2 (7): National Early Warning Score 2. A score used to assess and monitor acute illness severity based on six physiological variables.
CHA2DS2-VASc (8): Congestive Heart Failure, Hypertension, Age (>75 years, 2 points), Diabetes, Stroke (2 points), Vascular risk, Age (65–74), Sex category. A stroke risk assessment score applied to patients with atrial fibrillation. A higher score indicates greater risk.
MMSE (9): Mini-Mental State Examination. A 30-point scale used to measure cognitive impairment.
Clinical Frailty Scale (10): a nine-point scale used to predict functional decline, a higher score indicating increased frailty.
Modified Rankin Score (11): a scale (0–6) used to assess the degree of functional neurological disability following stroke or other neurological injury. A higher score indicates greater disability.
CURB65 (12): Confusion, blood Urea nitrogen, Respiratory rate, Blood pressure, (age) over 65. A clinical predictor score (0–5) for mortality risk in patients with pneumonia. A higher score indicates greater 30 day mortality risk.
Richter Scale (13): a magnitude scale based on the logarithm of the amplitude of waves recorded by seismographs. 1 is micro; 9.5 is the largest recorded earthquake.13
Acknowledgments
Mr Aongus Collins, who contributed the illustration.
Footnotes
Contributors The author is the sole contributor to the text. Mr Aongus Collins (collaborator) provided the figure.
Funding The author has not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient consent Not required.
Provenance and peer review Not commissioned. Externally peer reviewed by Charles Warlow, Edinburgh, UK.
Collaborators Aongus Collins.
Linked Articles
- Editors’ commentary