Expert answer:Stroke Case Study Questions

Answer & Explanation:Stroke Case Study I have attached 5 questions (highlighted) that need answered for this case study.Thank you!
initial_history.docx

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INITIAL HISTORY:
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76 year old man, slightly confused
Wife describes symptoms starting 30 minutes ago
Sudden onset of difficulty getting his mouth to form words; speech is slurred
Face and mouth numb; tongue feels ‘thick’
Unable to hold his coffee cup in his right hand
Right leg weak; needs to hold on to the table to stand
ADDITIONAL HISTORY:
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History of essential hypertension
Has not been taking his thiazide diuretic because it makes him feel ‘bad’
Was told he has high cholesterol but has not returned to see his primary care provider
Has experienced several brief spells of right-sided weakness which resolved in a few
minutes; thought this was his arm falling asleep
No head trauma or recent infections
Family history; mother died of stroke, father died of acute myocardial infarction (AMI)
Smokes 1 pack/day of cigarettes for the past 30 years
Sedentary lifestyle
Question 1: Now what do you think the diagnosis is?
PHYSICAL EXAMINATION:
➢ Alert and anxious white male
➢ Slurred speech, uses appropriate words
➢ T = 37 C, orally; RR=16; HR = 86 and irregular; B/P 190/120 mmHG (reclining).
HEENT:
➢ Conjunctiva clear without exudates or lesions
➢ Fundi without lesions, nicking, or cotton tufts
➢ Nasal mucosa is pink without drainage
➢ Oral mucous membranes are moist
➢ Pharynx is pink without lesions or exudates
Skin, neck:
➢ Pale with senile lentigines, no lesions or bruises
➢ No lesions or bruises, no tenting; dry and flaky
➢ Supple, no lymphadenopathy or thryomegaly
➢ Bruit auscultated over left carotid artery
Lungs:
➢ Chest expansion is symmetrical and full
➢ Diaphragmatic excursion is equal at 4 cm.
➢ Lung sounds are clear to auscultation
Cardiac:
➢ Heart sounds: irregular rate and rhythm
➢ No murmurs, gallops, or clicks
Abdomen:
➢ Nondistended; bowel sounds are present and not hyperactive
➢ Liver percusses 2 cm. Below right costal margin but overall 12 cm. in size
➢ No tenderness or masses; no bruits
Extremities:
➢ Cool but good capillary refill at 3 seconds
➢ 1 + pitting edema of bilateral ankles
➢ Radial artery pulses full and equal; anterior pedal pulses diminished but equal
➢ No clubbing
Neurological:
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Alert and oriented
Facial droop on right, with loss of nasolabial fold
Diminished gag reflex
Strength 3/5 in the right upper extremity and 4/5 in the right lower extremity; 5/5 in the
left upper and lower extremities
➢ Deep tendon reflexes (DTR’s) 1 + on right and 2 + on left
➢ Sensory intact to touch, no neglect
Question 2: What studies would you initiate now while preparing your interventions?
Question 3: What therapies would you initiate immediately while awaiting results of the lab
studies?
LABORATORY:
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EKG; atrial fibrillation
Serum glucose: 130 mg/dL
PT = 12.5 seconds; PTT = 28 seconds
Platelet count 220,000 per cubic mm.
Head CT scan without contrast media did not reveal evidence of bleeding.
EMERGENCY ROOM COURSE:
➢ Risks and benefits of thrombolytic therapy are explained to the patient and family
➢ Patient does not improve neurologically
➢ B/P improves with labetalol
PHYSICAL EXAMINATION UPDATE:
➢ Vital signs: B/P = 170/86; HR = 100, irregular
➢ Neurological exam:
o Alert and oriented
o Follows commands
o Right hemiparesis worsening; strength now 2/5 in both the upper and lower
extremities on the right, still normal on the left
o Moderate dysarthria
o Decreased sensation on the right
Question 4: What do you think is happening? Why is the hemiparesis worsening? What does
the CT scan mean? Should you continue to treat his hypertension to bring it down to normal?
Question 5: What interventions should be initiated now?
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