In this activity, carefully analyze the provided case study and identify pertinent positives and significant negatives

MSN 5041: Adult Gerontology Advanced Critical Care Concepts for Intensivist in Acute Care II

Case Study #1

Chief Complaint

A 50-year-old female is admitted to the emergency department with headache, dysarthria, and

left-sided weakness.

History of Present Illness

This 50-year-old female has not seen a doctor in a number of years and reports headaches over

the past 2 weeks, which she treated at home with ibuprofen. The night of admission, she went to

bed but woke around midnight to get some water and ibuprofen, and fell. Her husband heard her

fall and when he arrived at her side he noted she was not moving her left side and was confused

and disoriented. She also had garbled speech and was complaining of headache by holding her

head and moaning.

The husband called 911 and EMS arrived approximately 5 to 10 minutes after the fall. The

paramedics stated that she vomited en route to the hospital and again in the emergency

department (ED). Her blood pressure en route was 208 over palpable, she was in sinus rhythm,

and her blood sugar was 91. The EMS assessment also noted confusion, garbled speech, and

absence of movement on her left side to painful stimuli. EMS called the ED en route to initiate a

“stroke alert”. The estimated time elapsed from the fall to the patient’s arrival in the ED was 15

to 20 minutes.

General Survey

The AG-ACNP arrived at the patient’s bedside as she is being admitted to the ED and noted that

the patient’s altered and nonverbal status. Her speech is garbled and she is confused and

unaware of where she is. The AG-ACNP obtains some information from the patient’s husband.

He states that she has not been diagnosed with chronic medical problems such as diabetes,

hypertension, heart disease, cancer, and he is not aware of her ever having a seizure or stroke.

To his knowledge, she has not recent history of fevers, chills, nausea, vomiting, dyspnea, cough,

pain in the chest, abdomen, or back. She has not complained of numbness, tingling, paresthesias,

or edema of the extremities. Her mood and affect were normal with the exception of having

recurrent headaches.

Physical Examination

Vital signs upon arrival:

Temp 36.0 C oral

HR 79 beats per minute

RR 20 breaths per minute

BP 251/136 mm Hg with a mean arterial pressure (MAP) of 174 mm Hg

O2 sats 96% on 3L nasal canula

EKG at bedside showed sinus rhythm with a HR of 79 beats per minute

General appearance: Decreased mental status, she opens eyes to verbal and tactile stimuli and is

able to follow commands, yet with dense left hemiparesis (meaning no movement at all even to

painful stimuli).

HEENT: Normocephalic, atraumatic. PERRLA. The patient does have disconjugate gaze.

Normal extraocular movements with the right eye, left eye is unable to look laterally. Mucous

membranes moist, throat without erythema. Able to stick out her tongue to command without

noted deviation.

Cardiovascular: Regular rate and rhythm, no murmurs, rubs, or gallops, 2+ bilateral radial and

dorsalis pedis pulses

Pulmonary: No accessory muscle use or labored breathing, retractions, lungs are clear bilaterally

to auscultation, without wheezes, crackles, or rhonchi.

Gastrointestinal: Normal bowel sounds present in all 4 quadrants, abdomen is soft and

nontender, no masses.

Neurological: Initially opens eyes to verbal stimuli and follows commands with side 5/5 strength

and slight movement to left side 1/5 strength. However, within 5 minutes of arrival, and before

the head CT scan, her mental status rapidly deteriorates and she is unable to protect her airway or

follow commands. A positive left Babinski is noted. She is unable to follow commands with her

legs upon arrival, but on examination, both her left arm and left leg are flaccid with no

movement at all – even to painful stimuli. The patient initially had good grip strength with her

right hand but this deteriorates rapidly during the AG-ACNP’s assessment. The patient’s

National Institute of Health Stroke Scale (NIHSS) score is 28, but after her rapid decline, the

second NIHSS score is unobtainable due to her unresponsiveness.

Skin: Warm and dry, no rashes or lesions noted.

Musculoskeletal: Neck is supple, no cervical tenderness or palpable deformity. Extremities are

symmetrical and no lower extremity edema noted.

Psychiatric: Noncontributory.

Case Study Questions

1. What are the pertinent positive of this case?

2. What are the significant negatives of this case?

3. What laboratory and diagnostic testing should be ordered? Use national guidelines to support

your responses.

4. Discuss the National Institute of Health Stroke Scale (NIHSS) and its significance in this case.

5. Formulate your diagnosis and treatment plan. Use national guidelines to support your

responses.

Based on the provided case study, here are the responses to the questions:

1. **Pertinent Positives**:

– Headache: The patient reports headaches over the past two weeks, which may indicate an underlying neurological issue.

– Dysarthria: The patient exhibits garbled speech, suggesting impairment in articulation.

– Left-sided weakness: The patient experiences left-sided weakness, indicating a possible neurological deficit.

– Hypertension: The patient presents with severely elevated blood pressure (251/136 mm Hg), which could be related to the neurological symptoms.

– Altered mental status: The patient is confused and disoriented, exhibiting decreased mental status.

2. **Significant Negatives**:

– Lack of chronic medical problems: The patient has not been diagnosed with chronic medical conditions such as diabetes, hypertension, or heart disease.

– No recent history of fevers, chills, or other symptoms suggestive of an infectious etiology.

– No history of seizure or stroke, according to the patient’s husband.

– Absence of numbness, tingling, or paresthesias in the extremities.

3. **Laboratory and Diagnostic Testing**:

Based on the patient’s presentation and the suspected diagnosis of stroke, the following tests should be ordered:

– Head CT scan: This is essential for diagnosing acute stroke and determining the type (ischemic or hemorrhagic).

– Complete blood count (CBC) with differentials: To rule out infections or other systemic issues.

– Comprehensive metabolic panel (CMP): To assess electrolyte levels and renal function.

– Coagulation studies: Including prothrombin time (PT), activated partial thromboplastin time (aPTT), and international normalized ratio (INR) to evaluate for coagulopathies.

– Lipid profile: To assess cardiovascular risk factors.

– Electrocardiogram (ECG): To evaluate for arrhythmias or other cardiac abnormalities.

The American Heart Association/American Stroke Association guidelines recommend these tests for the evaluation of stroke patients.

4. **National Institute of Health Stroke Scale (NIHSS)**:

The NIHSS is a standardized tool used to assess the severity of stroke symptoms and guide treatment decisions. In this case, the patient’s NIHSS score of 28 indicates severe neurological impairment. The rapid decline in mental status underscores the urgency of intervention.

5. **Diagnosis and Treatment Plan**:

– Diagnosis: Acute ischemic stroke.

– Treatment:

– Immediate management should focus on stabilizing the patient’s airway, breathing, and circulation.

– Administer tissue plasminogen activator (tPA) if the patient meets eligibility criteria within the appropriate time window.

– Consult neurology for further evaluation and consideration of endovascular intervention.

– Initiate blood pressure management to reduce the risk of further neurological injury.

– Monitor for complications such as cerebral edema and intracranial hemorrhage.

The treatment plan aligns with the American Stroke Association guidelines for acute ischemic stroke management.

References:

– Powers, W. J., Rabinstein, A. A., Ackerson, T., Adeoye, O. M., Bambakidis, N. C., Becker, K., … & American Heart Association Stroke Council. (2018). Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke, 49(3), e46-e110.

Please note that the diagnosis and treatment plan provided are based on the information provided in the case study and may require further evaluation and adjustment based on clinical judgment and additional findings.