A 50-year-old female is admitted to the emergency department with headache, dysarthria, and left-sided weakness.
Case Study:
A 50-year-old female is admitted to the emergency department with headache, dysarthria, and left-sided weakness.
HPI.
This 50-year-old female has not seen a doctor in a number of years and reports headaches over the past 2 weeks, which she treated at home with ibuprofen. The night of admission, she went to bed but woke around midnight to get some water and ibuprofen and fell. Her husband heard her fall and when he arrived at her side, he noted she was not moving her left side and was confused and disoriented. She also had garbled speech and was complaining of headache by holding her head and moaning.
The husband called 911 and EMS arrived approximately 5 to 10 minutes after the fall. The paramedics stated that she vomited en route to the hospital and again in the emergency department (ED). Her blood pressure en route was 208 over palpable, she was in sinus rhythm, and her blood sugar was 91. The EMS assessment also noted confusion, garbled speech, and absence of movement on her left side to painful stimuli. EMS called the ED en route to initiate a “stroke alert.” The estimated time elapsed from the fall to the patient’s arrival in the ED is 15 to 20 minutes.
Physical Examination
• Vital signs on arrival: Temperature 36.0°C oral, heart rate 79 beats per minute, respiratory rate 20 breaths per minute, blood pressure 251/136 with a mean arterial pressure of 174 mm Hg, oxygen saturation 96% on 3L nasal cannula, ECG at bedside: sinus rhythm with rate of 79 beats per minute.
• General appearance: Decreased mental status, she opens eyes to verbal and tactile stimuli and is able to follow commands, yet with dense left hemiparesis (meaning no movement at all even to painful stimuli).
• Head/eyes/ears/nose/throat: Normocephalic, atraumatic. Pupils equal and round, reactive to light. The patient does have deconjugate gaze. Normal extraocular movements with the right eye, left eye is unable to look laterally. Mucous membranes moist, throat without erythema. Able to stick out her tongue to command without noted deviation.
• Cardiovascular: Regular rate and rhythm, no murmur, rubs, or gallops, 2+ bilateral radial and dorsalis pedis pulses.
• Pulmonary: No accessory muscle use or labored breathing, retractions, lungs are clear bilaterally to auscultation, without wheezes, crackles, or rhonchi.
• Gastrointestinal: Normal bowel sounds, abdomen is soft and nontender, no masses
• Neurological: Initially opens eyes to verbal stimuli and follows commands with right side 5/5 strength and slight movement to left side 1/5 strength. However, within 5 minutes of arrival, and before the head CT scan, her mental status rapidly deteriorates and she is unable to protect her airway or follow commands. A positive left Babinski is noted (which presents with upward flaring of the great toe). She is unable to follow commands with her legs upon arrival, but on examination, both her left arm and left leg are flaccid with no movement at all-even to painful stimuli. The patient initially had good grip strength with her right hand, but this deteriorates rapidly during assessment. The patient’s initial National Institutes of Health Stroke Scale (NIHSS) score is 28, but after her rapid decline the second NIHSS score is unobtainable due to her unresponsiveness.
The patient’s CT scan shows a large 6-cm right-sided intraparenchymal hemorrhage with a 16-mm leftward midline shift (Figure 68-1). While the patient was in the CT scanner, CT angiography was completed to assist with identifying the source of the bleed. Results did not identify an aneurysm.
Questions:
What elements of the review of symptoms and the physical examination should be added to the list of pertinent positives? Which items should be added to the list of significant negatives?
What is your diagnosis? How do you manage this patient going forward?
Answers should be in APA 7 format with in text citations and references
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