Question

Case Study Discussion Post:

CASE STUDY SCENARIO 6 PCH 265: Illness and Disease

- Provide a descriptive summary of case study in own words

-Provide a complete answer the assigned question

Charles is a 73-year-old man with several chronic medical problems wo experienced a life-changing event while eating dinner with his wife. He was eating his normal dinner consisting of meatloaf, au gratin potatoes, and canned green beans when he lost control of his fork. He was holding his fork in his right hand while bringing it to his mouth, it fell from his hand. Within seconds of this, he noted a sensation of heaviness in the upper arm and leg, causing his arm to fall at his side and his body to lean to the right. His wife noticed some dropping of the right side of his face and asked him what just happened. He was able to respond only with a brief grunt. As his wife attempted to ask him more questions, he became visibly frustrated but continued to only grunt in reply. He attempted to rise from his chair and fell to the ground. His wife screamed, got up from her chair and called 9-1-1. Emergency medical service (EMS) technicians arrived in seven minutes and took Charles to the nearest emergency room.

While in the emergency room (ER), his symptoms remained the same. HE was rapidly seen by an ER provider who reviewed his past medical history with his wife. Charles has been treated for high blood pressure and high cholesterol. He smoked for 40 years ranging from one to 3 packs per day. He lived a sedentary lifestyle following retirement from a local factory. His wife admitted that he was poorly compliant with his prescribed blood pressure medications and cholesterol medication due to side effects. After the brief history and examination, Charles was taken to the Computed Tomography (CT) scanner and a head CT was obtained, which was normal. Charles presented to the ER within 3 hours of the onset of his symptoms and was found to be a good candidate for tissue plasminogen activator (tPA), the clot busting drug. tPA was administered and over the subsequent days, his speech improved as did his weakness. Following a short hospitalization, Charles was transferred to a rehabilitation unit where he remained for several weeks. Following his discharge from the rehabilitation unit, he returned home but required a walker for ambulation and had significant impairments in his ability to speak full sentences.

Defining the Issues

Charles’ case demonstrates several important issues regarding stroke. First, based on the history and the evaluation, he has suffered an ischemic stroke. He has many risk factors for ischemic stroke including his age, high blood pressure, high cholesterol, and cigarette smoking. These risk factors have led to the development of atherosclerosis that affects not only the blood vessels supplying his brain but also those supplying the heart and extremities. As an individual, his risk of stroke could have been potentially decreased by alterations in his lifestyle including smoking cessation, exercise and changes in his diet. Additionally, the medical system could have lessened his risk of stroke by encouraging these lifestyle changes as well as emphasizing the importance of medication compliance. Ultimately, while he did not die from his stroke, he has suffered significant disability that will impact his day-to-day life as well as incur significant healthcare costs for the rest of his life.

Patient’s Understanding

Charles showed poor understanding of the importance of treatment of systemic disorders that predispose to the development of atherosclerosis. He was noncompliant with his medications to treat high blood pressure and high cholesterol. Unfortunately, this is common as there are no symptoms of these conditions. They are simply detected with vital sign checks or a blood draw, otherwise the patient is unaware of their presence. Additionally, he neglected to change his behavior at the time of these disorders were identified. His current diet remained high in fat and sodium after initial diagnosis, both of which can increase his chances of developing atherosclerosis. Additionally, smoking cessation and increasing his activity level may have modified these risks. In the acute setting however, he and his wife demonstrated good judgement in activating EMS immediately after the onset of his symptoms. This likely improved his ultimate outcome by making him eligible for tPA treatment.

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CASE STUDY SCENARIO 6 PCH 265: Illness and Disease Questions:

1. What steps would you recommend to Charles to change his long-term risk of stroke? Discuss medical and non-medical interventions and how you could help to ensure he accomplishes them.

2. How would your approach to question 1 change if Charles was 53 instead of 73?

3. Describe and explain the other problems or conditions must be considered for Charles.

Answer 1

• Keep your blood pressure in the normal range.
• quit smoking asap
• Keep your blood sugar (glucose) in the normal range.
• If you have heart disease, treat it.
• Keep your cholesterol levels in the normal range.
• Stay at a healthy weight.
• Get active.
• Eat healthy.
• take healthy foods like green leafy vegetables broccoli
• do regular exercises

. Older age, diabetes mellitus, hypertension, tobacco smoking, abnormal blood cholesterol (particularly, low high-density lipoprotein [HDL] and/or elevated low-density lipoprotein [LDL]), and other factors are either proven or probable risk factors for ischemic stroke, largely by their link to atherosclerosis. Risk of stroke is much greater in those with prior stroke or TIA. Many cardiac conditions predispose to stroke, including atrial fibrillation and recent MI. Oral contraceptives and hormone replacement therapy increase stroke risk, and although rare, certain inherited and acquired hypercoagulable states predispose to stroke. Hypertension is the most significant of the risk factors; in general, all hypertension should be treated to a target of less than 140– 150/90 mmHg. However, many vascular neurologists recommend that guidelines for secondary prevention of stroke should aim for blood pressure reduction to 130/80 mmHg or lower. The presence of known cerebrovascular disease is not a contraindication to treatment aimed at achieving normotension. Also, the value of treating systolic hypertension in older patients has been clearly established. Lowering blood pressure to levels below those traditionally defining hypertension appears to reduce the risk of stroke even further. Data are particularly strong in support of thiazide diuretics and angiotensin-converting enzyme inhibitors.

Several trials have confirmed that statin drugs reduce the risk of stroke even in patients without elevated LDL or low HDL. The Stroke Prevention by Aggressive Reduction in Cholesterol Levels (SPARCL) trial showed benefit in secondary stroke reduction for patients with recent stroke or TIA who were prescribed atorvastatin, 80 mg/d. The primary prevention trial, Justification for the Use of Statins in Prevention: An Intervention Trial Evaluating Rosuvastatin (JUPITER), found that patients with low LDL (<130 mg/dL) caused by elevated C-reactive protein benefitted by daily use of this statin. Primary stroke occurrence was reduced by 51% (hazard ratio 0.49, p = .004), and there was no increase in the rates of intracranial hemorrhage. Meta-analysis has also supported a primary treatment effect for statins given acutely for ischemic stroke. Therefore, a statin should be considered in all patients with prior ischemic stroke. Tobacco smoking should be discouraged in all patients. The use of pioglitazone (an agonist of peroxisome proliferator-activated receptor gamma) in patients with type 2 diabetes and previous stroke may lower risk of recurrent stroke, MI, or vascular death, but no trial sufficiently powered to definitively detect a significant reduction in stroke in the general diabetic population has yet been performed.

The problems like hypertension , DM , Myocardial infaction, COPD, Cardiac Arrythmias, kidney ds these all must be considered in charles and also he is very prone for these