*NURSING > iHuman > Walden UniversityNURS 6560iHuman WK10 Brad Banerjee. (All)

Walden UniversityNURS 6560iHuman WK10 Brad Banerjee.

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WK 10 – Neuro/Ortho/Plastics/Reconstructive Sx – Brad Banerjee 31 Y/O C/O: Acute dizziness, HA, and unsteady gait HPI: This is a 31 year old male with a past medical history significant for un... treated hypertension for 2 years, a recent smoker who quit 2 weeks ago and 2 days ago visited the ED with a right-sided headache and vertigo symptoms with Excedrin and Tylenol as the treatment plan for which he states has not helped. He presents today with the chief compliant of a sudden onset, deep, sharplike pain right-sided headache rated 6/10. He denies a history of migraines and in fact a history of any types of headaches. He states he rarely has headaches and has never had a headache like this before. This began 2 days ago while sitting at his desk at work when he felt this sharp pain suddenly. He also states when he stood up from his desk the “room was spinning” or he was spinning” and had to sit back down to keep from falling. The onset of vertigo began immediately after he felt the sharp pain in his head and has been constant ever since. He states moving his head and standing makes it worse and lying down and not moving makes it a little better. Yesterday he noticed a gradual onset of double vision which has not changed since it has started. He has moderate nausea that started around the same time as the other complaints did 2 days ago, however he denies vomiting. Also, last night he started hiccupping and it has not stopped. He has noticed that over the course of the past 2 days the right side of his face and left hand “feels strange” and his left leg “feels heavy”. He states he cannot walk without help, he stumbles from side to side, and he is consistently falling to the left side. Problem Statement: This is a 31 year old male with a past medical history significant for untreated hypertension for 2 years, a recent smoker who quit 2 weeks ago and 2 days ago visited the ED with a right-sided headache and vertigo symptoms with Excedrin and Tylenol as the treatment plan for which he states has not helped. He presents today with the chief compliant of a sudden onset, deep, sharplike pain right-sided headache rated 6/10. This began 2 days ago while sitting at his desk at work when he felt this sharp pain suddenly. He also states when he stood up from his desk the “room was spinning” or he was spinning” and had to sit back down to keep from falling. Other HPI complaints: Nausea; decreased appetite; right-side face and hand feels "strange; leftleg heaviness-having trouble walking; hiccups PE: pink conjunctiva, nystagmus, + romberg test, sitting ataxia-falling to the right PE-CHART eyes: nystagmus noted, conjunctiva pink, sclerae non-icteric, pupils equal round and reactive to light and accommodation, no drainage or discharge Musc: moves all extremities, normal bulk and tone, no rigidity, normal stability, asymmetric strength, weak left hand grip and left leg raise Neuro: Awake, alert, and fully oriented, cranial nerves I-XII intact, sensory grossly normal to touch and pin prick, deep tendon reflexes symmetrical 2+ throughout, no involuntary movements noted; broad-based stance & gait w/ falling toward right and sitting ataxia with falling to the right noted, + romberg's test Primary Diagnosis: 1. Stroke 2. Hypertension 3. Hyperlipidemia Thrombotic or embolic occlusion of a major vessel leads to cerebral infarction. Causes are identical to the disorders predisposing to TIAs. The resulting deficits depends on the particular vessel involved (Papadakis, McPhee, & Rabow, 2018). There are three major vessels supplying the cerebellum: superior cerebellar artery (SCA), posterior inferior cerebellar artery (PICA), and anterior inferior cerebellar artery (AICA). Cerebellar infarction can occur in any of these vascular territories, representing approximately 1.5–2 % of strokes (Picelli et al., 2017). Despite of it being a quite rare condition, the importance of cerebellar ischemic stroke is considerable because of its nonspecific clinical manifestations in the acute stage. Ataxia is a common disabling symptom of cerebellar stroke that involves disturbances in the control of gait (gait ataxia), voluntary limb movements (limb ataxia), speech (dysarthria), and eye movements (nystagmus) (Buard, Berliner, & Kluger, 2018). An obstruction of the posterior inferior cerebellar artery (PICA) can lead to the lateral medullary syndrome, characterized by vertigo and nystagmus, ipsilateral spinothalmic sensory loss involving the face, dysphagia, limb ataxia, and Horner Syndrome (Dziadkowiak, Chojdak-Łukasiewicz, Guziński, Noga, & Paradowski, 2016; Papadakis et al., 2018). Stroke due to occlusive large vessel disease has a higher morbidity and mortality than other strokes (Kondziella et al., 2013). Endovascular treatment (EVT) is an alternative option in ischemic stroke when intravenous thrombolysis treatment is contraindicated. EVT options include intra-arterial thrombolysis (our patient is outside this window and risk of hemorrhage outweighs benefit), mechanical clot removal (thrombectomy), and endovascular angioplasty (balloon dilatation and stenting). In posterior circulation stroke, the time window is 24hrs and beyond; the larger time window is owing to the often more protracted and fluctuating course of posterior compared to anterior circulation ischemia and the grave prognosis (90–95% mortality) without successful recanalization (Kondziella et al., 2013; Porter, Kaplan, & Lynn, 2018). This treatment option could be immediately performed in order to avoid the below circumstances, however that decision would be left up to the neurosurgeon. If the patient condition further deteriorates neuroimaging should be performed immediately and repeated often to determine the appropriate treatment strategy and, if possible, to rule out extensive brainstem infarction. Cerebellar stroke may lead to space-occupying edema, resulting in potentially fatal complications (Tartara et al., 2018). Ominous signs include progressive cranial nerve and pyramidal tract deficits, vomiting, hypertension, bradycardia, and especially a decreasing level of consciousness. Radiologic predictors for developing spaceoccupying edema are hypodensity of 2/3 or more of the cerebellar hemisphere, compression and/or displacement of the 4th ventricle, brainstem and basal cisterns, hydrocephalus, and hemorrhagic infarct transformation (Kondziella et al., 2013). Ventriculostomy is most commonly performed by inserting an extraventricular drain in a lateral ventricle. This procedure represents the gold standard of treatment and offers the opportunity for both measuring the supratentorial ICP and, if necessary, draining CSF along with Suboccipital Craniectomy which is a decompressive surgery to create space for the swollen tissue outside the narrow posterior fossa, thus avoid life-threatening compression of the brainstem and fourth ventricle (Neugebauer, Witsch, Zweckberger, & Jüttler, 2013). Patient will be started on a thiazide for hypertension and statin for hyperlipidemia for which he will need to have a repeat lipid panel within 2-4 weeks after starting to adjust dose [Show More]

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