M5 Case Study

• Points 76

CHIEF COMPLAINT: Sudden onset left-sided weakness.

HISTORY OF PRESENT ILLNESS

Sixty-six-year-old male who was at home when he suddenly developed left-sided weakness, slurred speech, and facial weakness at 7:00 PM. 911 was called and the patient was transported to the ED by the emergency medical service (EMS). Stroke pager activated at 7:44 PM and patient triaged at 7:51 PM. The National Institutes of Health (NIH) Stroke Scale (NIHSS) upon admission was 15. Head computed tomographic (CT) scan showed early right MCA infarct and intravenous tissue plasminogen activator (tPA) was given at 8:34PM. The patient was then taken to angiogram for evaluation of endovascular tPA but unsuccessful. The patient was intubated prior to angiogram secondary to airway protection.

PAST MEDICAL HISTORY: Hypertension treated with omlesartan (dose unknown by family).

CURRENT HOSPITAL MEDICATIONS

Atorvastatin 80 mg via nasogastric tube (NGT) daily.

Pantoprazole 40 mg via NGT daily.

Docusate sodium 100 mg via NGT twice daily.

Albuterol/ipratroprium/mucomyst nebulizer treatment every 6 hours.

Fentanyl intravenous (IV) administration 25mcg/hr.

Norepinephrine infusion 0.08 mcg/kg/min.

3% saline infusion at 30 mL/h.

Normal saline (0.9%) infusion at 75 mL/h.

Hydralazine HCL 10 mg IV every hour as needed for systolic blood pressure (SBP) > 185 mm Hg.

Labetalol 10 mg IV every 15 minutes as needed SBP >185 mm Hg.

Acetaminophen 325 mg by mouth every 4 hours as needed for temperature > 101.5F.

Potassium replacement per intensive care unit (ICU) protocol.

Regular insulin subcutaneously per ICU sliding scale protocol.

ALLERGIES: No known medication or food allergies.

SOCIAL HISTORY: Divorced. The patient has 2 daughters and 1 son. Support system also includes ex-wife; retired teacher.

BEHAVIORAL: The patient smokes 2 packs cigarettes per day; drinks 2 bottles of wine.

REVIEW OF SYSTEMS

Head: Denies any trauma, headache, or history of seizures.

Eyes: No visual field changes or blurred vision.

Chest: Positive for productive cough and shortness of breath prior to admission and during initial exam.

Heart: Denies any chest pain or chest pressure.

Circulation: Positive for numbness to left upper and lower extremities.

Abdomen: Denies abdominal pain, nausea, and vomiting.

Neurological: Positive for weakness and numbness to left side, positive for slurred speech, and facial drooping prior to admission.

General/Constitutional: In usual state of health prior to sudden onset of left-sided weakness, slurred speech, and facial drooping; currently denies pain.

Note: Intubated, unable to obtain full review of systems from patient. Parts of history and review of systems obtained from medical record and patient’s response on day of initial encounter.

PHYSICAL EXAMINATION

Vital signs: Temperature 99.2F oral, heart rate 70 beats per minute, blood pressure 110/70 mm Hg, mean arterial pressure 82 mmHg on norepinephrine at 0.08mcg/kg/min, respiratory rate 24 breaths per minute, O2 saturation 99% on 50% FIO2; height 170 cm, and weight 95.3 kg.

General: Overweight, orally intubated on mechanical ventilation, and in no acute distress.

Skin: Warm, dry, and both lower extremities cool.

Head, eyes, ears, nose, throat: Pupils 2 mm and equal, orally intubated, and bilateral scleral edema.

Chest: Bilateral expiratory wheezes and rhonchi left > right, copious yellow secretions, intubated on assist control rate of 12 breaths per minute, tidal volume 750 mL, positive end expiratory pressure 5, and FIO2 50%.

Heart: Regular, S1S2, no murmurs, clicks, or rubs.

Abdomen: Large, soft, bowel sounds active all 4 quadrants.

Extremities: Upper extremities warm, 2+ palpable radial pulses, both lower extremities cool, Doppler pulses only to right and left posterior tibial, no edema noted, left radial arterial line, right forearm peripheral IV, and right femoral sheath.

Musculoskeletal strength: right upper extremity 5/5, left upper extremity 1/5, right lower extremity 4/5, and left lower extremity 1/5.

Musculoskeletal tone: Normal in right upper extremity and right lower extremity, flaccid to left upper extremity, and increased tone to left lower extremity.

Neurological: Richmond Agitation Sedation Scale negative 1 (1), drowsy, oriented 3, follows command to right side only, NIHSS 14, moderate sensory loss to left side, partial extinction to left, left facial weakness, visual fields intact, extraocular movements intact, and Glasgow Coma Scale 14.

Genitourinary: Foley catheter, urine output approximately 50 mL/hour, fluid balance +2647 mL, and nurse reports leakage of urine around Foley catheter.

DIAGNOSTICS

Laboratory Findings:

Computed tomography of head (day of admission): Dense right MCA and possible early obscuration of the gray-white interface in the anterior right temporal lobe consistent with right MCA stroke.

Cerebral angiogram post IV tPA: Endovascular manipulation with no revasculariation and persistent right M1 occlusion.

Chest radiograph (morning of first encounter): Bilateral atelectasis.

Electrocardiogram: Normal sinus rhythm.

Based on the main diagnosis of this patient you, the nurse practitioner identify, you will submit your case study completed in the sections identified below:

1. Definition of diagnosis you suspect in this patient

2. Epidemiology

3. Etiology/Classification

4. Risk Factors of the diagnosis – emphasize with an asterisk (*) the risk factors this patient exhibits

5. Pathophysiology

6. Clinical Presentation (including History and Physical Exam pertinent findings of the typical presentation of this diagnosis)

7. Diagnosis (including criteria, laboratory findings, imaging)

8. Management of the disease

9. Prevention of recurrence

10. Complications and Prognosis

Bonus- Differential Diagnoses. If you accurately list the pertinent differential diagnoses for this patient, you will be awarded bonus points per the rubric.

Note: Use 3 or more references. List your content in sections denoting the headings 1-10 and in the order listed above. Bonus differential diagnoses can be included at the end of your submitted case study

Rubric

Case Study Rubric Week 5 (1)

Case Study Rubric Week 5 (1)

Criteria	Ratings	Pts
This criterion is linked to a Learning OutcomeEpidemiology, Etiology/Classification & Risk Factors	16 ptsExcellentComplete inclusion of epidemiology, etiology/classification data, and pertient risk factors12.44 ptsGoodIncomplete inclusion of epidemiology, etiology/classification data, and pertient risk factors. Missing 1-4 data points. 8.89 ptsFairIncomplete inclusion of epidemiology, etiology/classification data, and pertient risk factors. Missing 5 or more data points.0 ptsNo MarksNo inclusion of content for this topic	16 pts
This criterion is linked to a Learning OutcomePathophysiolgy	21 ptsExcellentComplete inclusion of pathophysiology content16.5 ptsVery GoodIncomplete inclusion of pathophysiology content. Missing 1-2 data points. 10.5 ptsGoodIncomplete inclusion of pathophysiology content. Missing 3-4 data points.6 ptsFairIncomplete inclusion of pathophysiology content. Missing 5 or more data points.0 ptsNo MarksNo inclusion of content for this topic	21 pts
This criterion is linked to a Learning OutcomeClinical Presentation & DiagnosisClinical Presentation (including History and Physical Exam pertinent findings), Diagnosis (including criteria, laboratory findings, imaging)	19 ptsExcellentComplete inclusion of clinical presentation & diagnosis criteria. Missing no more than 1 data points.15.83 ptsGoodIncomplete inclusion of clinical presentation & diagnosis criteria. Missing 2-4 data points. 11.08 ptsFairIncomplete inclusion of clinical presentation & diagnosis criteria. Missing 5 or more data points.0 ptsNo MarksNo inclusion of content for this topic.	19 pts
This criterion is linked to a Learning OutcomeManagement of the Disease, Prevention of Recurrence & Complications and Prognosis	16 ptsExcellentComplete inclusion of management of the disease, prevention of recurrence & complications and prognosis data points. Missing no more than 1 data points.12.44 ptsGoodIncomplete inclusion of management of the disease, prevention of recurrence & complications and prognosis data points. Missing 2-4 data points. 8.89 ptsFairIncomplete inclusion of management of the disease, prevention of recurrence & complications and prognosis data points. Missing 5 or more data points.0 ptsNo MarksNo inclusion of content for this topic.	16 pts
This criterion is linked to a Learning OutcomeBonus: Differential Diagnosis	0 ptsFull Marks3 Bonus Points Possible: Accurately list the 3-4 most PERTINENT differential diagnoses for this patient in order to receive points.0 ptsNo MarksNo partial points will be awarded.	0 pts
This criterion is linked to a Learning OutcomeReferences3 or more references listed in APA format.	4 to >0.8 ptsExcellent3 references. Correctly cited. Appropriate quality resources.0.8 to >0 ptsNo Marks	4 pts

Total Points: 76

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