Kathy is 67 years old. She presented

Kathy is 67 years old. She presented to her GP last week, complaining of a very strong headache, followed by dizziness. The symptoms had resolved by the time she could see the GP, who was concerned enough to request a CT (computerised tomography) of Amelia’s head and neck. Medical History : Diabetes mellitus Type 2: Management: metformin 1000mg, daily enalapril 10 mg daily rosuvastatin 10mg, daily Atrial fibrillation (AF) Management: apixaban 2.5 mg, BD sotalol 40 mg, BD Cigarette smoking: 20 – 30 cigarettes/day, quit 5 years ago. GP -Diagnostic 1 week ago Amelia underwent a CT scan of the head and neck, but the results were normal. Amelia was assessed asârequiring changes to herâhypertension & AF management andâthe following changes made: enalapril ceased the following medications commenced or changed; irbesartan/ hydrochlorothiazideâ300/25, daily amlodipine 5mg, daily apixaban 5mg, BD. Today: Amelia woke early this morning at 0600 hours with a 5/10 headache. At 0700 hours she began to feel weak in her limbs, and her headache increased to 7/10. One side of her face began to “feel strange”. She was able to call her neighbour, who brought her to hospital. Emergency Department Time is nowâ 0800.â Vital signs:â RR: 18 bpm SpO2: 98% BP: 180/92 mmHgâ (MAP 121 mmHg) HR: 98 bpm Temp: 37oC Pain assessment:â Provoking/palliating: pain is worse when Amelia moves her head suddenly, nothing seems to relieve the pain Quality: the pain feels like extreme pressure on theâleftâside of her head Region/radiation: the pain is confined to her head Severity: 9/10 Timing:âfirstâpain onsetâwas about 2 hours ago Neurological assessment:â GCS: 15 Pupils: PERRLA ROSIER (Recognition of stroke in the emergency room) Scale Loss of consciousness or syncope: NO Seizure activity: NO Asymmetric facial weakness: YES Asymmetric arm weakness: YES (rightâupper limb paralysisâ-âunable to respond to movement request) Asymmetric leg weakness: YES (rightâlower limbâparesis – mild weakness) Speech disturbance: YES (some slurring of words (dysarthria) is noted) Visual field deficit: NO Other: Limb sensation:ârightâupper limbâanaesthesia;ârightâlower limbâ- paraesthesia (tingling feeling).â Amelia appears pale and anxious. She has not had her medications today. â Cardiovascular assessment An ElectroCardioGram (ECG) is undertaken which showsânormal sinus rhythm.ââââ Blood tests are ordered including full blood count (FBC), urea & electrolytes (U&Es), liver function tests (LFTs), coagulationâstudies (COAGs) including Anti-Xa levels. Metabolic assessment Blood Glucose Level (BGL): peripheral 9.8 mmol/L (Amelia reports not having eaten since yesterday, nor has she had her medications today)â Computerised Tomography report Exam Information Modality: CT Body Part: NEURO Description: CT Brain Performed Date: 25/3/Year Time: 0830 Final Report CT BRAIN CLINICAL NOTES: Patient presents with severe headache, dysarthria, limb anaesthesia, paresis, and paralysis. CT 7 days ago – no adverse findings Findings: A non- contrast CT has been acquired. Nil intracranial haemorrhage noted. Complete occlusion of the left middle cerebral artery noted. IMPRESSION: Middle cerebral artery thrombosis (not conclusive). Intervension: review by stroke team nil by mouth until swallow assessment 1/24 (hourly) vital signs and then as per “Thrombolysis for ischaemic stroke pathway” after commencement of thrombolysis therapy 1/24 (hourly) neurological assessment for 4 hours, then 4/24 (four hourly) for 72 hours 6/24 (six hourly) blood glucose monitoring for 72 hours alteplase infusion as per protocol telemetry for at least 24 hours nurse patient with bed head elevated to 30o intravenous therapy-fluid order 1: List all Kathy’s risk factors that could have contributed to her current presentation. Describe all risk factors, with reference to relevant anatomical structures, describe the associated pathophysiological mechanisms and how they led to Kethy’s presentation, stating the relevant information from the case scenario.

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