Patient is middle aged (early 60s), smokes a pack per day, calls EMS after falling off the toilet and being unable to get up secondary to left sided onset of weakness. Gets TPA after arriving in the E.R. after being found to have 90-100% occlusion to vessels I cannot now remember. Recovers some movement and function of left extremities, has significant left facial droop. Trauma during Foley attempt in ER leads to necessity of suprapubic cath. Admitted to Neuro ICU where patient goes into ETOH withdrawal, is vented and placed on Ativan GTT. Recovers from withdrawal after a few days, weaned from vent. Significant aphasia present, aspirating own secretions. Made strict NPO, NG tube placed for tube feeding and meds. Occasional need for oral suction.
Patient transferred to PCU. Left side nearly flaccid with minimal movement noted. Patient moans constantly, incomprehensible sounds, no sensible verbalizations. Follows commands unreliably. Not always responsive to voice. CXR shows aspiration pneumonia and patient is on Vanc and Merrem. On 4L NC, spo2 93%, SR in the 80s, SBP 130s. Elevated sodium with orders for 250 ml FW flushes q6h, returns even more elevated the following morning and FW flushes ordered q4h now. Patient moaning constantly, becomes diaphoretic. Gradually pulse increases to ST in the 110-120 range, patient becomes agitated, attempting to sit up. Follows no commands. Spo2 tanks to 89% on 4L NC after breathing treatment, BP increases to 164/101. Obvious labored with see-saw respirations and mild supraclavicular contractions. Nonrebreather placed and patient placed sitting up to 90 degrees, spo2 improves to 99%. MD notified and ABGs are ordered, demonstrating respiratory alkalosis and metabolic alkalosis. CTA negative for PE. CT head shows no changes from previous. CXR shows no changes from previous. Cardiac enzymes, blood and urine cultures, EKG all pending at the time of transfer to ICU.
Ideas on what may have been going on with this patient and other courses of action that might have been taken? This isn't homework, it was my patient yesterday. I felt glad to recognize a problem and avoid a rapid response situation but patient's overall condition baffled me. Patient had been eating, following commands and making some verbalizations prior to transfer to stepdown. Decline was gradual over a few days and then culminated in rapid decline on my shift.
