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NEURO CASE

By: Charmaine Baniqued

Patients Profile

Chief complaint

> Washing clothes when sudden onset of slurred speech, blurred vision & right-sided facial weakness was experienced

CVD, hemorrhagic Left basal Ganglia, HPN

Assessment (ER) Past Medical History Family History Socio-Environmental History

Pathophysiology

Risk Factors:

-Family history of hypertension (both Parents)


Fatty deposition in blood vessels walls, making the lumen narrow, hence the cause of increase blood pressure -Age 52y/o female, menopause -High Triglyceride, and cholesterol level -High fat diet

Decrease estrogen in menopause stage. Estrogen has a BP lowering effect

Epithelium of blood vessel walls decreases elasticity with age Cell membrane alteration Possible chronic, undiagnosed and uncontrolled hypertension True/ apparent cardiomegaly

Prolonged vasocostriction

Stimulates arterial smooth muscles, hypertrophy and hyperplasia

Inflammatory response

Release of Histamine, Leukotriene, Prostaglandin

Increased vascular permeability

Increased Na, Ca, H2O, CHON, Humoral substances

Decreased vessel thickening

Increased soft muscle contractions

Further Vasoconstriction

Increased peripheral resistance

Increased BP (Hypertension) systemic circulation

Blurring of vision
Slurred speech Right sided facial weakness

Uncontrolled HPN

Progressively thinner and more fragile arterial wall

Rupture of blood vessels Change in LOC Basal Ganglia, Left, CVD Hemorrhagic Emergency craniectomy for evacuation of blood clot at left parietotemporal area

Affected Brocas area

Affected precental gyrus (1 degree somatic motor area controlling muscles)

Expressive speaking aphasia

Right sided loss of sensory and motor function

Difficulty swallowing

Impaired Verbal Communication

Impaired swallowing Risk for imbalanced nutrition Risk for aspiration Risk for aspiration

NGT insertion

Receptive aphasia Self-care Deficit Impaired physical mobility Activity intolerance Ineffective Role Performance Joint management of PT/OT Risk for possible urine retention

Risk for Skin Integrity


Risk for Constipation Risk for injury

IFC insertion

Ensures accurate measurement of adequate urine output and efficacy of diuretic therapy

CT Scan (head)
Date Result 12/01/12 (+) basal ganglia hemorrhage, left. Approximately 46cc Acute left capsuleganglionic hemorrhage with secondary lateral ventricular compression and minimal subfalcine herniation 12/03/12 Almost complete resolution of acute capsuloganglionic hemorrhage; still with minimal mass effects Minimal pneumocephaly Implication/s Hemorrhagic stroke, left basal ganglia Intervention/s For emergency craniectomy evacuation of hematoma (left parietotemporal area) Nicardipine drip initiation Mannitol administration 150 cc stat Continuous monitoring of VS and NVS Mannitol 100cc q8 Furosemide 20 mg IV 3) min. post Mannitol

Successful craniectomy

CBG/ FBS
Reference Value 70110mg/dL

Date

Result

Implication/s

Intervention/s

12/01/12 119mg/ dL

Normal; done For FBS to determine comorbidity of DM and hypertension Above normal: OF: low fat, low could be an salt, diabetic effect of diet physiologic stress or possible DM

12/08/12 176mg/ dL (pre-BF)

65-99mg/ dL

ABGs Analysis
Date
12/01/12

Result
pH: 7.276 PCO2: 39.1 HCO3:17.6

Reference Value 7.35-7.45 35-45 mmHg 22-26 mmol/L

Implication/s
Metabolic acidosis: increased formation of acid in the body probably due to shifting to anaerobic metabolism (lactic acid build up)

Intervention/s
O2 inhalation @ 1 LPM/ NC

12/02/12

pH: 7.470 pCO2: 31.9 HCO3: 22.9

Respiratory alkalosis: may Anti-diuretic be due to the effect of admin cerebral edema on CNS that (mannitol, may cause stimulation to furosemide) the respiratory center Normal For repeat ABGs

12/03/12 AM

pH: 7.411 pCO2: 39.8 HCO3: 24.8 pH: 7.436 pCO2: 37.4 HCO3: 24.7

PM

Normal

Complete Blood Count


Date 12/01/12 Result WBC:5.79 Hgb:155 Reference Value 5-10 x 10e9/l 110-150 g/L Implication/s Normal WBC count High: May mean decrease oxygen level in the body Increase WBC: presence of an inflammatory process or the physiologic stress brought about by the surgery Still high: May mean decrease oxygen level in the body High: indicates decreased oxygenation in the body or dehydration due to diuretic use Intervention/s > O2 inhalation @ 1 LPM/ NC Anti inflam meds given, antibacterial drugs Maintenance of O2 inhalation at 1 LPM/NC

12/05/12

WBC: 10.8

Hgb: 166

Hct: .511

.37- .47 L/L

12/10/12

WBC: 12.9

Elevated WBC may be contributed to the presence of pneumonia


Hgb is almost normal while the Hct is WNL, indicative of good oxygenation in the body.

Hgb: 151 Hct: WNL

Serum ALT
Date 12/01/12 Result 26.4 U/L Reference Value F: 7-35U/L Implication/s Normal; was done to identify any damage to the liver which could be affected such as in the case of a fatty liver, hence may interfere drugs to be prescribed for the patient

Serum Creatinine
Date Result Reference Value Implication/s

12/01/12 77 umol/L

44-80

Normal; for determination of renal function High; Possibly dehydrated


Normal

12/06/12 103 umol/L

12/10/12 77 umol/L

Serum Sodium
Date Result Reference Value
136-145 mmol/L

Implication/s
Normal High; May indicate dehydration or may be due to the NGT feeding with inadequate fluid Normal

Interventions
Low salt, low fat OF preparation

12/01/12 141 mmol/L 12/03/12 154 mmol/L 12/06/12 153 mmol/L

12/10/12 142mmol/L

Serum Potassium
Reference Value 3.5-5.1 mmol/L

Date

Result

Implications Normal Hypokalemia; due to loop diuretic use

Interventions

12/01/12 3.96 12/03/12 3.78 12/10/12 2.91

Incorporation of 40 mEqs KCl in IVF and Kalium durule

12/12/12 3.50

Normal

Discontinued KCl and Kalium durule

Activated Partial Thromboplastin time


Date Result Reference Value 26.0-36.0 seconds Implications Interventions

12/01/12 38.1 seconds

Prolonged; No salicylates since there given was a WOF coffee bleeding, ground there were aspirates circulating products of fibrin and fibrinogen degradation in the blood, hence the increase.

Prothrombin time and activity


Date Result Reference Value Implications

12/01/12 10.6 seconds I.N.R : 0.93

9.8 -12.7 sec Normal Less than 2.0 for patients not receiving anticoagulatio n therapy

Urinalysis
Date 12/01/12 Result Implications

Reaction Metabolic alkalosis :alkaline Albumin:positive+ Probably benign proteinuria owing to physiologic stress Reaction :acidic Albumin:negative

12/05/12

Serum glucose

Date

Result

Reference Values 4.11- 5.89 mmol/L

Implications Increased; due to CVA (acute stress to the body)

12/02/12 6.60 mmol/L

Lipid Profile
Date Result 12/02/12 HDL 1.15 Reference Value 0.91.56 mmol/L Implications WNL Interventions Low fat, low salt OF

Triglyceride Less than 1.70 1.96 2.25 mmol/L


Cholesterol 6.15 0.0-5.2 mmol/L

Limits within borderline high risk


Hypercholesterolemia; levels are higher in overweight and obese populations; hypertension

LDL 4.61

2.59- 3.34 mmol/L High; May be due to diets high in cholesterol and fats;history of familial hyperlipoproteinemia; and obesity

Uric Acid
Date Result Reference Value 2.4- 5.7 mg/ dL Implications High; hyperuricemia: hypertension

12/02/12 10.8

Chest Xray Portable


Date
12/05/12

Result
Bilateral pulmonary hypoinflation True or apparent mild cardiomegaly

Implications

Interventions

May be evident Turn side to of a restrictive side q2 lung disorder Maintenance due to obesity of O2 therapy

Review of Medications 12/10/12


Omeprazole Mannitol Furosemide Levofloxacin IV Carvedilol Stafloxin Nicardipine Levopront Citicoline Simvastatin Kalium durule Amlodipine Losartan plus Clonidine Allopurinol Lactulose Fluimucil Hydrocortisone Ceftazidime Combivent

Review of Medications12/17/12
Zykast Carvedilol Losartan plus Cefixime Citicoline Simvastatin

Allopurinol Lactulose Fluimucil Lansoprazole Amlodipine Combivent

Review of Systems
General Survey HEENT Cardiovascular Respiratory

Nutrition GI Musculoskeletal Neurologic

END Thank You..