Question

Mrs. Anna Temple, A 40-year-old African American woman, arrives at the emergency room, with her husband Joe. According to Mr. Temple, his wife woke up at 7 am to get ready for work. Mrs. Temple was unable to get out of bed due to weakness in her left arm and left leg. Mr. Temple also noticed the left side of his wife’s face was drooping. Upon arrival at the ED, Anna Temple had a left facial droop, left-sided hemiparesis, expressive aphasia, and mild dysphagia.

Anna’s past medical history includes atrial fibrillation (afib), hypertension, hyperlipidemia, and Type 2 Diabetes (NIDDM), anxiety, and depression. Anna’s past surgical history includes: hysterectomy, cholecystectomy, right knee arthroscopy, and incision and debridement of a left groin abscess.

Anna is awake, alert, and oriented x 3. Anna is unable to verbalize answers to questions due to expressive aphasia but is able to nod yes/no to staff. Heart rate is 101, and irregular. Lungs are clear bilaterally. O2 sat is 98% on RA. She has positive bowel sounds, positive +2 pedal pulses, and +1 bilateral edema of her lower legs. Anna’s husband reports that Anna has been complaining of numbness and tingling to her feet. Anna has also been c/o nausea and loss of appetite, and loose stools for 3 days. Anna is straight catheterized for a urine specimen. 300 cc of dark amber malodorous urine. Anna is quickly taken for a CT scan of the brain.

Vital signs, T: 37, HR, 101 irreg, RR 24, BP 188/98. Anna denies pain. Her blood sugar on admission was 242. #18 gauge IPID RFA.

Social History: Obtained from Mr. Temple. (while Anna was in CT scan).

Anna and Joe Temple have been married for 20 years. They have twin daughters, age 19, and a son, age 16. Their daughters are both freshmen in college, and their son is a sophomore in high school. Last year, Anna’s mother, who has early onset dementia, came to live with them after Anna’s father passed away from a heart attack. Joe’s parents live next door, and both have many medical appointments which Joe and Anna help take them to. Anna works full time as an administrative assistant for an insurance company. Anna often confides in Joe that her job is very stressful and rarely is able to get away from her desk for lunch or a break. Joe also says that Anna is always taking care of everyone else and is not consistent with her medications or her own doctor’s appointments. Anna has smoked 1 ppd for the last 20 years.

MEDS: Daily/PRN: Glucophage 500 mg po BID, Lopressor 25 mg po BID, Lipitor 20 mg po QD, Xarelto 20 mg po QD, Neurontin 300 mg po TID, Multivitamin 1 po QD, Premarin 0.3 mg po QD, Zoloft 100 mg po QD

Lab Results:

RBC 4.1                      Platelets- 450,000                  CL 110

WBC 16.2                   INR 1.0                                   Mag 1.4

HGB 11g/dl                K 2.8                                       Hbg A1C 12 %

HCT 32.3%               Na 148                                    Glucose 259

·Urinalysis: +2 bacteria, +3 leukocytes, +2 protein, trace RBCs,

·Diagnostic tests: non contrast CT scan: thrombolytic CVA.

·CXR: bilat bibasilar atelectasis, EKG: afib,

Mrs. Temple has returned from CT scan and tPA is administered per protocol.

In addition to tPA, the physician enters the following orders:

IV 0.9 NSS 125 cc/o, Vital signs & Neuro checks q 15 min x 4, then Q 30 min x2, then Q 1 hr. NPO until swallowing evaluation. 1 GM Rocephin IV, novolog per sliding scale, BGM ac and hs.

After Mrs. Temple’s vital signs stabilized, she was transferred to the neuro medical surgical unit with admission diagnoses of CVA, LSW, uncontrolled DM, HTN, and +UTI

STROKE:

1.      What is tPA, and why was it appropriate for Mrs. Temple?

2.      Why is Mrs. Temple NPO?

3.      What were Mrs.Temple’s risk factors for stroke?

4.      Explain how knowing the type of CVA is an important factor in treatment.

5.      What is the NIH stroke scale?

6.      Why would it be important to continue neuro checks in the hours following a CVA?

MEDICATIONS:

7.      Why do you think Anna Temple was prescribed each of these medications (look at home medications)

8.      Which of these medications may be contraindicated for Anna Temple based on her medical and surgical history?

SOCIAL HX:

9.      What additional risk factors are noted in the social hx information? How do these risk factors affect other aspects of Mrs. Temple’s health…..DM, HTN, Anxiety, Depression….

It is now 3 days post CVA for Mrs. Anna Temple, Anna’s deficits continue to improve, she is ambulating with a walker and standby assist. She is tolerating a LFLC consistent carb diet regular consistency with honey thick liquids. Anna is pleasant but with a very flat affect, very tearful at times. Anna’s vital signs and blood sugars are now within normal range. Anna will likely be discharged to acute inpatient rehab prior to transitioning to home.

10.  What diagnostic test was likely done by the speech therapist to determine that Anna needed honey thick liquids for safe swallowing?

11.  Identify actions to help Mr. and Mrs. Temple as they learn to cope with Mrs. Temple’s recovery and the other responsibilities of their busy lives.

Answer 1

Answer -1 TPA administration

10%of the total treatment dose administer as in form of intial bolus over in one minute

remaning dose given intravenously in next 60 minutes ist a emergency conditional maintain electrolytes and water in body dehydration and also work in diabetic patients

answer-2 NPO means nothing per oral physicians want to observe thier reflux of swallowing

answer 3 chances of stroke are hyperlipidmia lipids increase in vessels cause arthroscelorsis makes vessels narrow bloody supply interrupt also triggered faster is hypertension increased blood pressure increased workload on heart left ventricle load increase in end heart unable to pump some cause defect in LADA ARTERY WIDOW ARTERY

answer - NIH stroke scale - lies between -0 to 4

if patient action is normal 4 points should given

if nil in action 0 should be given

national institutes of health add in thier scale for stroke is

1. level of conicousness

2. level of conicusness question

3. LOC commands

4. Movement of eye

5. visual fields

6. facial Parsis

7. motor arm left and right

8. sensory activeness

9. Dysarthria

Answer -10 honey helps in swallowing oral motor exercise

Answer-11 thier family encouraged them to exercise daily for mouth chewing swallowing grinding excerise