Stroke

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Stroke: a guide to diagnosis and assessing severity
Introduction
Figure 1. Each year in the UK 110 000 people have a first stroke and 30 000 people have recurrent strokes.

Paul Rapson/SPL

Each year in the UK 110 000 people have a first stroke and 30 000 people have recurrent strokes. Some 10 000 strokes occur in people younger than 65 and 60 000 people die from having a stroke.4 Provisionof acute care for patients with stroke in the UK has received national attention over the past few years. The National Sentinel Audits of Stroke, conducted four times between 1999 and 2004 by the Royal College of Physicians of London, have consistently shown that despite considerable progress in the development of services, standards of care (particularly acute care) remain below acceptablelevels. 5 Standard five of the Government's National Service Framework for Older People recommends that all patients with a stroke requiring urgent hospital admission should be treated by specialist stroke teams within designated stroke units and that care should be provided in line with the National Clinical Guidelines on Stroke. 6 7 Patients need medical and nursing input at least as intensive asthat provided on a coronary care unit. It is important that affected patients receive care in stroke units that is: Organised Interdisciplinary Delivered by specialists in stroke care. History You should ask about:
What happened and when

Any previous medical history (particularly related to cerebrovascular or cardiovascular disease) Medications they are taking Family history Functional andsocial history.

Learning bite You should ask young or middle aged patients (and sometimes older people) about a history of cocaine or other drug use. Common symptoms of stroke Stroke can impact on virtually all human functions. 11 It can affect:
Motor ability (both gross and fine) Walking Mood Speech Perception Cognition.

These impairments can affect the patient's capacity to carry out basic andinstrumental activities of daily living. Focal cerebral ischaemia usually results in loss of a function (negative symptoms such as loss of power or sensation) rather than a positive event such as limb jerks or visual hallucinations. Most ischaemic events start suddenly, which means the patient or their family should be able to tell when symptoms started or what they were doing when symptomsstarted. Likewise, the neurological symptom or sign is described as "focal" when the clinical deficit can be anatomically localised. When this occurs suddenly it is usually a result of cerebral ischaemia. Symptoms also tend to be maximal at onset and then either progress or remain the same in a vascular event. Symptoms that are unlikely to be due to a transient ischaemic attack or stroke are unusual ornon-focal symptoms and therefore do not suggest a vascular event. These include:
Transient loss of consciousness Confusion Generalised weakness Transient forgetfulness Hearing loss Vertigo on its own.

You can see focal neurological symptoms with other conditions, such as migraine, partial epileptic seizure, intracranial space occupying lesions, multiple sclerosis, hypoglycaemia, and StokeAdams attacks. Therefore, taking an accurate history is essential for diagnosing a transient ischaemic attack or stroke. Conditions commonly misdiagnosed as transient ischaemic attacks include:
Syncope Seizures Sepsis Somatisation (such as a conversion disorder).

Learning bite Traditional textbooks say that hemiplegic migraine is a common differential diagnosis, but it is, in fact, rare. Muchmore common is a patient with an old stroke whose signs worsen during an intercurrent illness such as an infection. Quick improvement is usual with appropriate treatment.

When making a diagnosis, remember that:
Most transient ischaemic attacks last minutes rather than hours Most ischaemic events start suddenly Focal neurological symptoms or signs usually result from cerebral ischaemia Negative...
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