Mrs. Amelia Middleton is a 68 year old retired receptionist who is bought in by ambulance to the
emergency department (ED) of her local hospital. Her son Paul is with her. Paul had called the
ambulance service earlier stating that his mother woke this morning complaining of a headache
and is now unable to lift her right arm and has been having difficulty speaking.
On examination Mrs. Middleton has a BP of 200/110, pulse 78 and irregular, respiratory rate 16,
SpO2 98%, Glasgow Coma Scale 12, and Temp 36.8. Her blood sugar level is 4.8mmol/L. She
also has paralysis of the right arm and face and loss of sensation to touch on the right side of her
face and right arm. She appears to understand what is being said to her but cannot respond
verbally. Mrs. Middleton’s history includes depression and lower gastrointestinal bleeding
associated with haemorrhoids. She has no known allergies. Mrs. Middleton is an only child. Her
father died of an anterior myocardial infarction at age 57 and her mother died of breast cancer at
Mrs. Middleton currently lives with her son after the recent death of her husband, Geoff. She is in
the process of trying to sell the family home. She has three other children, all of whom live
Amelia Middleton’s current medications are:
Sertraline 100mg mane
Rectinol HC topically as required
At the time of arrival Mrs. Middleton had a provisional diagnosis of CVA/stroke.
Mrs. Middleton was ordered a CT scan which was conducted 6 hours after her arrival to ED, the
results excluded the presence of a haemorrhagic stroke but indicated ischaemic stroke.
A 12 lead ECG was also conducted on arrival and Mrs. Middleton was found to be in atrial
This assessment task requires to apply the Clinical Reasoning Cycle (CRC) to the above case
study, using the following questions/instructions to guide and organise response.
answers should be presented in an integrated essay-format (rather than short-answer responses)
and be informed and supported by reading of current research and literature.
1) What additional data/cues would you gather in regard to this case, and how and why would
this be performed?
2) Draw upon existing knowledge and relevant scholarly literature to process the above
3) Given that the diagnosis of ischaemic stroke has already been confirmed, identify and
explain two other issues/problems for Mrs Middleton that emerge from your analysis of the
data (remember, these do not necessarily have to be other specific diagnoses/conditions,
but could be particular problems that arise due to the stroke).
4) Select one of these issues/problems and establish a clear goal for your care.
5) Discuss your key actions/interventions for achieving this goal, drawing upon appropriate practice literature