MBChB Curriculum Map

Mr Harry Webster, a 70-year-old retired printer, is talking (on the 3rd floor landing outside his flat) to his retired neighbour, Mr Fred O’Reilly, about his wife going weak down one side and collapsing last week). “She had a ‘funny turn’ last month - a few minutes - but this was much worse. Her arm and face on one side jerked violently... foaming at the mouth. I was desperate - phoned 999! Hospitals are busy after Friday night pub ‘closing time’, but Meg was so embarrassed at being examined in the corridor - felt like an invasion of privacy. She’s home now, but can’t get out from up here. I’m having to help her a lot.” Mr O’Reilly asks, “How are you coping Harry – bit of a change? Meg usually runs around after you with your bad back”.

Dr Ken Kumar reads Mrs Webster’s discharge letter: “…neurological examination of this 69 year-old lady suggested left middle cerebral artery thrombosis with contralateral hemiplegia. …The ‘MRI scan’ showed evidence of advanced atherosclerotic changes with slightly dilated ventricles... Radiographs showed osteoporosis of the vertebral column”. [Dr Kumar is aware that the history of imaging is relatively recent, but it is crucial to anatomical understanding.]

Mrs Webster is referred for community-based rehabilitation but is unsure what to expect, and worries about ‘ageism’. Dr Kumar ensures that a physiotherapist and speech therapist visit her as part of her home care plan. After four weeks, the visiting social worker reassesses her, and indicates that the Websters may not be eligible for any social support. Dr Kumar visits Mrs Webster at home. Mr Webster is very distressed: “This sounds bad, but Meg is such a burden. She says her face feels funny. Her speech is so hard to follow, we both get frustrated. She’s also had another twitching bout. She can’t move her arm properly - even swallowing food and medicine is difficult. We’re not seeing our friends now. Living up here is such a handicap, let alone the stroke.” While there, Dr Kumar checks Mr Webster’s blood pressure - he has been feeling “a bit faint. Meg is a big woman to lift.” “This lifting is bad for your spine”, says Dr Kumar. Their reduced quality of life is clear and he feels he must find more help to ‘limit damage’ further. Given patient confidentiality, Dr Kumar asks Mrs Webster if he can discuss her details with Social Services.

Dr Kumar discusses Mrs Webster with Dr John Wise, his partner. They note cohort study evidence giving a relative risk of 4.0 (95% confidence interval 1.6 to 8.2) for stroke in high-risk groups. Dr Kumar is encouraged that Mrs Webster survived. “Our local stroke-specific SMR is so high. Material deprivation and high unemployment make things worse around here. Could her stroke have been prevented? Patients like Mrs Webster can be such a challenge.” Dr Wise says, “Is that SMR adjusted for social class? What routine data would describe the long-term prospects for post-stroke disability?”