Confusion / Delirium OSCE - Stroke

Diagnosis: Stroke

Case Overview

  • Age/Sex: 69-year-old male
  • Occupation: Retired factory supervisor
  • Setting: Lives alone; found confused at home by neighbour
  • Chief complaint: "I'm confused and not myself"

Patient Script

Who I Am

I'm a 69-year-old retired man who lives alone; I used to work in a factory and I usually manage my own chores.

What Brings Me In

I woke up this morning and I wasn't right — I feel muddled, my speech is slurred, and I can't move my right arm properly.

My Story

I usually get up around 7 am. This morning I woke up and felt a bit odd, but I thought I would shake it off. Around 9:30 am I suddenly noticed I couldn't lift my right arm and my speech became very slurred. I tried to call my neighbour and she came round at about 10:00 am and said I was "not making sense" and looked confused, so she called an ambulance. I feel like I knew things before but now I keep losing my words and I can't hold my cup with my right hand. I also have a bit of droop on the right side of my face when I try to smile. I didn't hit my head and I didn't faint.

I did have a mild cough last week and took some over-the-counter cold tablets. I started a new tablet for my prostate "a few days ago" which made me a bit dizzy one evening. I had a minor stumble getting out of the shower last week but no head injury. I usually drink a couple of beers at night but I haven't been drinking heavily recently.

My Medical Background

  • Hypertension for many years (I sometimes forget my pills)
  • Past atrial fibrillation diagnosed 2 years ago (I'm on aspirin only)
  • High cholesterol
  • No previous stroke or TIA that I know of
  • Medications: amlodipine (not always regular), aspirin 75 mg daily, atorvastatin, tamsulosin started 4 days ago (for urine problems)
  • Allergies: penicillin (rash years ago)
  • Social: lives alone, non-employed, used to smoke (20 pack-years, quit 10 years ago), drinks 2–3 beers nightly
  • Family: father had a heart attack in his 70s

What I Think & Worry About

  • I think something serious is wrong with my head — I'm frightened I'm having a stroke.
  • I'm worried I might lose my independence and not be able to look after myself anymore.
  • I'm concerned I may have done something wrong with my tablets because I forget doses sometimes.

If You Ask Me About Other Symptoms...

  • Headache: "I have a little headache but nothing terrible."
  • Vision: "Things on the right look a bit fuzzy, like I don't see as well on that side." (reports blurred right visual field)
  • Numbness: "My right arm feels weak, like it's dead — my right leg is a bit weak too when I try to stand."
  • Speech: "My words are coming out funny and I keep searching for words."
  • Chest pain/breathlessness: "No chest pain, I can breathe OK."
  • Fever/other infection signs: "I had a cough last week but I don't feel hot now — maybe a bit clammy."
  • Urinary symptoms: "I've been getting up a lot at night to pee lately, but no burning."
  • Recent head trauma or seizure: "No fits or head bumps — I just stumbled last week getting out of the shower but I was fine after that."

Clinical Summary

Examination

  • General: alert but disoriented to exact time; appears acutely unwell
  • Vital signs: BP 188/112 mmHg, HR 110 bpm irregularly irregular, RR 18/min, SpO2 97% on air, Temp 37.8°C
  • GCS: 14 (Eye 4, Verbal 4 — mildly confused, Motor 6)
  • Cranial nerves: right lower facial droop; right-sided visual field deficit on confrontation testing
  • Speech: dysarthric with word-finding difficulty
  • Motor: right-sided flaccid weakness — power R arm 1/5, R leg 2/5; L arm 5/5, L leg 5/5
  • Sensation: reduced light touch on right upper and lower limb compared with left
  • Coordination: left-sided coordination intact; cannot adequately test right due to weakness
  • Reflexes: brisk on the right with upgoing plantar on the right
  • Cardiorespiratory: heart irregularly irregular with no murmurs; chest clear
  • Other: no obvious signs of head injury; mild urinary urgency on questioning

Investigations

  • Finger-prick glucose: 6.1 mmol/L (no hypoglycaemia)
  • ECG: atrial fibrillation, ventricular rate ~110 bpm
  • Non-contrast CT head: no acute intracranial haemorrhage; early evidence of left MCA territory hypodensity not clearly demarcated (consistent with early ischaemic change)
  • CT angiography (if performed): occlusion of the proximal left middle cerebral artery (possible large vessel occlusion)
  • Full blood count: WCC 9.0 x10^9/L (normal), Hb 14.2 g/dL
  • Urea & electrolytes: Na 138 mmol/L, K 4.1 mmol/L, creatinine 85 µmol/L
  • INR: 1.0
  • CRP: 12 mg/L (mildly raised)
  • Chest X-ray: clear
  • Urinalysis: trace leukocytes (possible contamination/very mild UTI or asymptomatic)

Diagnosis

  • Primary: Acute ischaemic stroke — left middle cerebral artery (MCA) territory due to cardioembolic event from atrial fibrillation.

    • Evidence: acute onset focal neurological deficits (sudden right-sided weakness, facial droop, dysarthria, right visual field deficit), CT head without haemorrhage, ECG with AF, CT angiography showing left MCA occlusion.

  • Differentials:

    • Intracerebral haemorrhage: less likely because CT shows no bleed but must be excluded early (CT done).
    • Hypoglycaemia: excluded by normal glucose.
    • Seizure with post-ictal paresis (Todd's paralysis): possible but no witnessed seizure activity; persistent focal deficit and imaging favor stroke.
    • Delirium due to infection (UTI/pneumonia): low-grade fever and trace leukocytes on urinalysis are possible red herrings; focal deficits/localising signs point to stroke.
    • Acute vestibular syndrome or peripheral neuropathy: does not explain facial weakness, visual field defect, and cortical signs.

Management

  • Immediate (first minutes to hours):

    • Time last known well established (neighbor reports patient was well the night before; symptoms noticed at ~9:30–10:00 am) — patient appears within thrombolysis window.
    • ABCs: ensure airway patent, oxygen if SpO2 <94% (not required here), continuous monitoring.
    • NPO and urgent swallow screen by trained staff before oral intake.
    • Rapid non-contrast CT head performed to exclude haemorrhage (already done) and CT angiography for large vessel occlusion assessment.
    • Check blood glucose immediately (6.1 mmol/L) — treat if abnormal.
    • If no contra-indications and within window, consider IV alteplase (thrombolysis) — withhold antiplatelet agents until after CT decision per local protocol.
    • For proximal large vessel occlusion on CTA and if within mechanical thrombectomy window, arrange urgent transfer to endovascular-capable centre for thrombectomy.
    • Blood pressure management: maintain BP <185/110 mmHg if considering thrombolysis (current BP 188/112 — consider cautious lowering per stroke protocol).
    • Start cardiac monitoring and address atrial fibrillation; avoid immediate anticoagulation until imaging and specialist input (anticoagulation typically deferred for 24–48 hours post-ischaemic stroke depending on size and risk).

  • Early inpatient care:

    • Admit to stroke unit.
    • Initiate secondary prevention after acute decisions: high-intensity statin (if not already), start antiplatelet therapy if thrombolysis not given or as per protocol after bleeding excluded, and plan for anticoagulation for AF after appropriate interval.
    • Multidisciplinary referrals: speech and language therapy (dysphagia and communication), physiotherapy, occupational therapy, social work for home safety and support planning.
    • Monitor for complications: aspiration, raised intracranial pressure, recurrent stroke, infections.

  • Longer term:

    • Cardiology/echo to look for cardiac source of embolus if not already known beyond AF.
    • Risk factor optimisation: blood pressure control, smoking cessation reinforcement, alcohol moderation, diabetic control if present.
    • Plan for rehabilitation and assessment of capacity and home support given he lives alone.

Key Learning Points

  • In suspected stroke, establish the exact time last known well quickly — time-sensitive therapies (thrombolysis, thrombectomy) depend on it.

  • Focal neurological signs (asymmetric weakness, facial droop, visual field deficits, dysarthria) with sudden onset strongly suggest acute stroke; exclude mimics (hypoglycaemia, seizure, infection) rapidly.

  • Early non-contrast CT head is essential to exclude intracranial haemorrhage; CT angiography helps identify large vessel occlusion and eligibility for thrombectomy.

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