Case 1 Amelia is a 68-year-old woman

Case 1 Amelia is a 68-year-old woman who was brought into ED by her neighbour. She woke this morning at 0600 hours with a 5/10 headache. At 0700 she called her neighbour and asked her to bring her to hospital when she began to feel weak, and her headache increased to 7/10. At this time, one side of her face began to “feel strange”. She has past medical history of Atrial fibrillation (AF), hypertension (HT) and dyslipidaemia which she manages with Apixaban 2.5mg BD, Sotolol 80mg daily, Amlodipine 5mg daily, Irbesartan/hydrochlorothiazide 300/25mg daily, Rosuvastatin 10mg daily. Amelia used to smoke 20 cigarettes/day but states she quit 5 years ago. When she was brought into ED, she told staff that she did not take her medications this morning as she was too distracted by her increasing headache. You are assigned to care for Amelia. As you are about to enter her room, you overhear Amelia crying to her neighbour, explaining that she is worried as her mother had died of a stroke. ROSIER score Mild facial weakness Limb strength: Left side: normal; Right side: right arm no response, right leg weak A slight speech disturbance No visual issues CT scan of the Brain (CTB) Amelia has had a left middle cerebral artery occlusion. This artery irrigates the primary motor and somato-sensory corticol areas of the brain. Vital sign BP 180/94 HR 80 RR 19 SpO2 97% Temp 37 -BGL = 8.1mmol/L -GCS Eyes – Eyes remain open at all times Verbal – You ask Amelia what the year is, she responds by saying “It’s 2023”. You ask Amelia where she is and she responds by saying “in a hospital”. You ask Amelia what her name is and she responds “Amelia Hayes”. Motor – Amelia can obey all of your commands when asked. -Pupillary response assessment Both pupils are equal and reactive to light: 4+ -Limb strength assessment Right upper limb = none Right lower limb = mild weakness Left arm and leg = normal -ECG Amelia’s ECG shows she is experiencing Atrial Fibrillation (AF). – PQRST ASSESSMENT P: The pain is worse when Amelia moves her head suddenly – nothing seems to relieve the pain Q: The pain feels like extreme pressure on the left side of her head R: The pain is confined to her head S: 9/10 T: The first pain onset was about 4 hours ago Amelia’s pathology results pH 7.37 ( 7.3-7.4) PCO2 44 (40-50mmHg) PO2 95 (80-100mmHg) HCO3 28 (22-32meq/L) SaO2 97 (95-100%) Na+ 138 (134-145mmol/L) K+ 3.8 (3.5-5.0mmol/L) Cl- 100 (95-105mmol/L) Urea 6 (2.5-6.7mmol/L) Creatinine 130 (70-150μmol/L) RBC 6.0 (4.5-6.5 1012/L) WBC 8.0 (3.5-11.0 109/L) Platelets 360 (150-450 109/L) Hb 140 (115-165g/L) Hematocrit 0.44 (0.37-0.47 LL) Anti-Xa 8 Case 2 Luke Marks is a 40-year-old male who was brought into ED by ambulance after he came off his motorcycle at 40km/hr after hitting a pothole in the road. The incident was called in by a bystander, an off-duty lifeguard, who helped to stabilise his c-spine by supporting his head (in a badly scratched helmet) and spoke to him until paramedics arrived. Handover from paramedics included: GCS 15, PERRLA, nil evidence of head injury despite a head strike, but Luke was unable to move his arms and legs and stated he had nil sensation in his legs and the sensation in his hands felt strange. The paramedics safely removed his helmet and safely secured a hard collar around his neck before transporting him to hospital. Luke reported pain of 8/10 in his cervical spine but nowhere else. His vital signs were as follows: RR 22, SpO2 98% RA, HR 59bpm, BP 125/63 mmHg, Temp 35.7 degrees. Paramedics administered 8mg IV ondansetron, 5mg s/c morphine and 250ml of NaCl (0.99%) en route. Luke has no significant medical history and takes no regular medications. You are assigned to care for Luke. When you enter his room, he is visibly upset and asks you, “What is happening to me? Why can’t I feel my legs?”. Vital Signs BP 100/70 HR 52 RR 25 (shallow) SpO2 95% on RA Temp 35.4 Electrocardiogram (ECG): Luke’s ECG shows he is in normal sinus rhythm (SR). PQRST assessment P – I have pain at rest & pain when I move my neck. Nothing makes it better Q – Sharp stabbing pain R – Neck S – 10 out of 10 T – After crashing my motorcycle Blood Glucose Level (BGL): BGL is 5.5mmol/L Clinical data gathered: — Peripheral Assessment: CR <3 secs Peripheries warm + pink No peripheral oedema ----- BGL 5.5mmol ----- Respiratory assessment: Look - pink, symmetrical + shallow chest movements Feel - shallow chest movements Listen - bilateral air entry, nil adventitious sounds Clinical data gathered: --- .Reflex assessment: Upper- minimal bicep brachii, no tricep or wrist extension. All other upper reflexes absent. Lower- all absent. ---- Sensation assessment: Luke can only feel from the top of his head to 2cms above his nipple line. --- Respiratory assessment: E- Luke's eyes are open as you approach V- When asked what year it is, Luke responds by saying '2023'. When asked where he is at the moment, Luke responds by saying 'at the hospital'. M- When asked to open and close his eyes three times, Luke is able to do so. Medical Imaging: CT Spine: C6 lesion with no vascular haemorrhages noted but some blood evident at C5 - 6 with bone fragments in the spinal canal. CT Brain: NAD Cervical spine x-ray: unstable C6 compression fracture Chest x-ray: decreased lung expansion upon inhalation; mild pulmonary oedema Pupillary response assessment: Both pupils are equal and reactive to light: 4+ Limb strength assessment: Arms = Spastic flexion Luke is able to elevate shoulders and isometrically contract biceps brachii slightly in both arms, could not raise either arm against gravity Legs = None Luke's lower limbs are flaccid and have no ability to move Based on ABCDE assessment findings justify which patient requires prioritisation of care. Explain the underlying pathophysiology of the condition in relation to the abnormal clinical cues.

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