Simulated Patient Scenario

Acute Stroke

Scenario Details

Scenario: Acute onset neurological deficit - Suspected Stroke

Simulated Patient: 68-year-old Male Mannequin or Actor

Actor/Actress: Spouse (present on scene, provides history)

MDT Information

Urgent response - Possible Stroke / CVA
68-year-old male with sudden onset weakness
Patient responding abnormally
Patient breathing normally
Spouse present

On Arrival

Patient is sitting in an armchair in the living room. He appears distressed, with noticeable left-sided facial droop and slurred speech. His left arm is resting limply in his lap. Spouse is standing beside him, anxious.

Initial Impression and Primary Survey

Category	Finding
Initial Impression	Obvious distress, left facial droop, slurred speech, left arm weakness.
Response	Opens eyes to voice, attempts to speak but speech is slurred and difficult to understand (dysarthric/aphasic). Obeys commands with right side, weak effort on left. (AVPU = V/P)
Airway	Clear, but potential risk due to facial weakness/dysphagia.
Breathing	Rate and effort appear normal.
Circulation	Skin warm, colour normal. Radial pulse strong and regular.
Disability	Significant neurological deficit (facial droop, arm weakness, speech difficulty).
Exposure/Environment	Indoor home environment, safe. Patient wearing day clothes.

Secondary Survey and Simulation Progression

History

Allergies	Penicillin (rash)
Medications	Ramipril 10mg daily, Atorvastatin 20mg nocte, Metformin 1g BD, Aspirin 75mg daily.
Past Medical History	Hypertension, Type 2 Diabetes Mellitus, Hypercholesterolaemia, Ex-smoker (quit 10 years ago). No previous stroke or TIA.
Last Oral Intake	Breakfast (toast and coffee) approx 2 hours ago.
Events Preceding / Time Last Seen Well	Spouse reports patient was completely normal watching TV approx 45 minutes ago. He suddenly complained of feeling "strange", then his face drooped and speech became slurred. She noticed his left arm was weak when he tried to stand. She called emergency services immediately. Time last seen well: 45 minutes ago.

Vital Signs/Assessment (Initial)

Parameter	Value
Resp. Rate (/min.)	16
Lung Sounds (L/R)	Clear bilaterally
SpO2 (%)	97% (Room Air)
EtCO2 (mmHg)	N/A
Pulse Rate (/min.)	88, Regular
CRT (sec.)	< 2 sec
ECG rhythm	Sinus Rhythm
12-lead ECG	Sinus rhythm, no acute ischaemic changes.
BP (mmHg)	175/95
Skin	Warm, dry, normal colour.
Pain (/10)	0/10 (Patient denies pain, may report headache if asked specifically).
GCS (/15: E,V,M)	12-13/15 (E4, V3-4 - slurred/confused, M5-6 - localises/obeys R>L) - Score may vary based on assessment.
BGL (mmol/L)	8.2
Pupils (mmL/mmR)	3mm L / 3mm R, Equal and Reactive
Pupil reac. (L/R)	Equal and Reactive
Temp. (°C)	36.9

Physical Examination (Focused Neuro Exam / Stroke Screen)

**Facial Droop:** Present on Left (ask patient to smile/show teeth).
**Arm Drift:** Left arm drifts downwards rapidly when held out; Right arm holds position.
**Leg Weakness:** Left leg weak against resistance/gravity; Right leg normal strength.
**Speech:** Dysarthria (slurred) and/or Aphasia (difficulty finding words/understanding).
**Vision:** May report blurred vision or visual field defect (hemianopia) - Assess via confrontation if possible.
**Grip Strength:** Weak on Left, Normal on Right.
**Sensation:** May be reduced on Left side (assess light touch).
**Coordination:** Difficult to assess due to weakness, but likely impaired on Left.
**(Use local stroke screening tool e.g., FAST, MASS, RACE, etc.)**

Assessment and Treatment

Appropriate Management

Recognise signs/symptoms of acute stroke. **Time critical emergency.**
Confirm time last seen well (critical for thrombolysis/clot retrieval).
Primary survey (ABCDE), ensure airway patency. Consider positioning (semi-upright if tolerated and airway secure).
Perform focused neurological assessment / stroke screen (e.g., FAST/MASS).
Obtain vital signs, including BGL (rule out hypoglycaemia as mimic).
Oxygen therapy ONLY if SpO2 < 94%. Avoid routine high-flow oxygen.
Establish IV access (large bore cannula, preferably antecubital fossa on unaffected side - Right arm). Avoid excessive attempts.
Do NOT administer Aspirin or other antiplatelets/anticoagulants pre-hospital unless directed by specific protocol/receiving facility.
Manage blood pressure according to local stroke guidelines (often permissive hypertension is allowed unless extremely high or specific contraindications exist). Avoid rapid lowering unless indicated (e.g., >220/120 or specific circumstances).
Keep patient Nil By Mouth (NBM) due to risk of aspiration.
Minimise on-scene time. Rapid transport is crucial.
**Pre-notify receiving hospital (Stroke Alert):** Provide age, gender, time last seen well, key neurological findings (stroke screen results), vital signs (esp. BP, BGL), ETA.
Transport patient safely, minimising movement, continuous monitoring en route.
Provide reassurance to patient and spouse.