Question

medical terminology)

case study for patient case

find and add more medical terms up to 100 and put underline each term)

Introduction:

The patient Mr. J, a 58 years old African-American, admitted in the Emergency Department with complaints of loss of balance followed by the altered level of consciousness (ALOC), left-sided hemiparesis, dysarthria, and facial droop. He denied chest pain, visual disturbances, cephalalgia, trauma, bowel incontinence, urinary incontinence, etc. He had stable vital signs except blood pressure of 150/90 mm of Hg, indicating hypertension. After necessary diagnostic tests, the physician diagnosed the case as a cerebrovascular accident (CVA).

Past Medical History:

Mr. J was diagnosed with diabetes mellitus (DM) type 2 at the age of 40 years. He was taking some herbal remedies at first, but is on antidiabetic agents as per physician's prescription for eight years. He is also on antihypertensives for three years. He also has a history of hypercholesterolemia and gouty arthritis, an inflammatory condition of joints, especially the hallux joint, due to deposition of urate crystals, but he is not on any medications for that. He is having a poor compliance with the medication regimen. Currently, he is taking ACE (angiotensin-converting enzymes) inhibitors, beta-blockers for his hypertension, and an antihyperglycemic agent, Metformin, for diabetes mellitus.

Family History:

Mr. J's father died from myocardial infarction (MI). He had a history of hypertension (HTN), coronary artery disease (CAD), and benign prostatic hyperplasia (BPH). Mother is suffering from diabetes mellitus (DM) and is on insulin. She also has a history of inflammatory bowel disease (IBD).

Assessment results:

revealed diagnostic evaluation with head CT scan showed ischemic stroke. Blood samples taken revealed hypercholesterolemia with cholesterol level 300 mg/ dL (milligrams per deciliter), high-density lipoprotein (HDL) 40 mg/dL, and low-density lipoprotein (LDL) 150 mg/dL. His fasting blood sugar (FBS), random blood sugar (RBS), or glycosylated hemoglobin were not obtained. He is on Metformin for hyperglycemia.

Results revealed that the patient is having an attack of right-hemisphere ischemic cerebrovascular accident.

Consent: Patient consent was obtained for a detailed eye examination referral.

****Disease condition:

Stroke (cerebrovascular accident): The loss of brain function arising from the sudden interruption of cerebral blood supply. It might be of two types; hemorrhagic CVA and ischemic CVA. Hypertension and hyperlipidemia are the two main risk factors of CVA. Other risk factors are smoking, obesity, family history, etc.

The main causative factors are:

1. Thrombosis (clot formation) due to atherosclerotic plaques.

2. Embolism or cardiogenic emboli.

Actions taken:

1. Intravenous (IV) injection of TPA (recombinant tissue plasminogen activator).

2. Administration of antiplatelet blood thinners, aspirin.

3. Vital signs monitoring q.4 hours.

4. Management of intracranial hypertension (IH) with diuretics.

Nursing assessment:

1. Assessment of neurological status to know the severity of CVA.

2. Altered level of consciousness (ALOC).

3. Nuchal rigidity.

4. Assessment for any dysarthria (difficulty in articulating words) and dysphagia (difficulty in swallowing).

5. Skin color of face and extremities.

Results:

The wife said, he has now changed towards the better by incorporating healthier meals and less junk food items. She mentions that he has had a difficult time in the past few years with diabetes, hypertension, gouty arthritis, etc. Change in lifestyle along with therapies and the addition of a service dog aided improvements along with his family support system. The patient spends lots of time outside with his dog and has started working on small projects, which keeps him active. She also states that the patient’s HbA1c (glycosylated hemoglobin) has not been tested for almost three months and that it needs to be tested as his RBS (random blood sugar) is high. The patient visits his podiatrist regularly for peripheral neuropathy and is on B vitamins q. daily; however, his neuropathy is on remission since undergoing transcutaneous electrical nerve stimulation (TENS). The patient’s wife is also doubtful about his mental status with increasing forgetfulness pointing towards dementia. She also remembered that he once complained of visual aura while doing gardening and after that he had photophobia for a while. She says he needs to undergo a dilated eye examination to diagnose retinopathy as he is complaining of blurred vision and floaters occasionally with some dry eyes. She says he uses over-the-counter Visine eye drops as a remedy, which she understood is for keratoconjunctivitis sicca.

Answer 1

The client Mr. J, a 58 years old African-American, admitted in the Emergency Department with problem of imbalance followed by the altered level of consciousness (ALOC), left-sided hemiparesis, dysarthria, and facial droop. He denied chest pain, visual disturbances, cephalalgia, trauma, bowel incontinence, urinary incontinence, etc. He had stable vital signs except blood pressure of 150/90 mm of Hg, indicating hypertension. After necessary diagnostic tests, the physician diagnosed the case as a cerebrovascular accident (CVA).

Past Medical History:

Mr. J was diagnosed with diabetes mellitus (DM) type 2 at the age of 40 years. He was taking some herbal remedies at first, but is on antidiabetic agents as per physician's prescription for eight years. He is also on antihypertensives for three years. He also has a history of hypercholesterolemia and gouty arthritis, an inflammatory condition of joints, especially the hallux joint, due to deposition of urate crystals, but he is not on any medications for that. He is having a poor compliance with the medication regimen. Currently, he is taking ACE (angiotensin-converting enzymes) inhibitors, beta-blockers for his hypertension, and an antihyperglycemic agent, Metformin, for diabetes mellitus.

Family History:

Mr. J's father died from myocardial infarction (MI). He had a history of hypertension (HTN), coronary artery disease (CAD), and benign prostatic hyperplasia (BPH). Mother is suffering from diabetes mellitus (DM) and is on insulin. She also has a history of inflammatory bowel disease (IBD).

Assessment results:

revealed diagnostic evaluation with head CT scan showed ischemic stroke. Blood samples taken revealed hypercholesterolemia with cholesterol level 300 mg/ dL (milligrams per deciliter), high-density lipoprotein (HDL) 40 mg/dL, and low-density lipoprotein (LDL) 150 mg/dL. His fasting blood sugar (FBS), random blood sugar (RBS), or glycosylated hemoglobin were not obtained. He is on Metformin for hyperglycemia.

Results revealed that the patient is having an attack of right-hemisphere ischemic cerebrovascular accident.

Consent: Patient consent was obtained for a detailed eye examination referral.