In this activity, carefully analyze the provided case study and identify pertinent positives and significant negatives. Additionally, suggest any additional labs or diagnostic tests that could provide valuable insights, and provide your primary diagnosis with a rationale. Mention any relevant national guidelines you would reference for this case. Assignment must follow APA 7th edition guidelines.
Refer to grading rubric in Moodle:
1. Understanding of the Case (30%):
Demonstrates a clear understanding of the patient's condition, medical history, and current symptoms.
2. Diagnostic Reasoning (25%):
Shows logical and effective diagnostic reasoning, including differential diagnoses and appropriate diagnostic tests.
3. Management Plan (25%):
Develops a comprehensive and evidence-based management plan, including pharmacological and non-pharmacological interventions.
4. Interprofessional Collaboration (10%)
Demonstrates understanding of the roles of other healthcare professionals and includes appropriate referrals and consultations.
5. Professionalism and Writing Quality (5%):
Writes in a clear, concise, and professional manner, free of grammatical errors.
6. APA 7th Edition Guidelines (5%):
Correctly uses APA 7th edition formatting for all references and in-text citations.
MSN 5041: Adult Gerontology Advanced Critical Care Concepts for Intensivist in Acute Care II
Case Study #1
Chief Complaint
A 50-year-old female is admitted to the emergency department with headache, dysarthria, and
left-sided weakness.
History of Present Illness
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 was 15
to 20 minutes.
General Survey
The AG-ACNP arrived at the patient’s bedside as she is being admitted to the ED and noted that
the patient’s altered and nonverbal status. Her speech is garbled and she is confused and
unaware of where she is. The AG-ACNP obtains some information from the patient’s husband.
He states that she has not been diagnosed with chronic medical problems such as diabetes,
hypertension, heart disease, cancer, and he is not aware of her ever having a seizure or stroke.
To his knowledge, she has not recent history of fevers, chills, nausea, vomiting, dyspnea, cough,
pain in the chest, abdomen, or back. She has not complained of numbness, tingling, paresthesias,
or edema of the extremities. Her mood and affect were normal with the exception of having
recurrent headaches.
Physical Examination
Vital signs upon arrival:
Temp 36.0 C oral
HR 79 beats per minute
RR 20 breaths per minute
BP 251/136 mm Hg with a mean arterial pressure (MAP) of 174 mm Hg
O2 sats 96% on 3L nasal canula
EKG at bedside showed sinus rhythm with a HR 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).
HEENT: Normocephalic, atraumatic. PERRLA. The patient does have disconjugate 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 murmurs, 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 present in all 4 quadrants, abdomen is soft and
nontender, no masses.
Neurological: Initially opens eyes to verbal stimuli and follows commands with 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. 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 the AG-ACNP’s assessment. The patient’s
National Institute of Health Stroke Scale (NIHSS) score is 28, but after her rapid decline, the
second NIHSS score is unobtainable due to her unresponsiveness.
Skin: Warm and dry, no rashes or lesions noted.
Musculoskeletal: Neck is supple, no cervical tenderness or palpable deformity. Extremities are
symmetrical and no lower extremity edema noted.
Psychiatric: Noncontributory.
Case Study Questions
1. What are the pertinent positive of this case?
2. What are the significant negatives of this case?
3. What laboratory and diagnostic testing should be ordered? Use national guidelines to support
your responses.
4. Discuss the National Institute of Health Stroke Scale (NIHSS) and its significance in this case.
5. Formulate your diagnosis and treatment plan. Use national guidelines to support your
responses.