Case Study #2

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Specializes in being a Credible Source.

A lot of people seemed to like my last real-life case study and I had another interesting one last night... so thought I'd post it.

Here goes...

40-year-old woman was at work when she experienced sudden and acute onset of numbness, tingling, and weakness in her R arm and the R side of her face.

She was rushed through triage to an open room but none of the pod nurses heard the call... I got involved when a call went out that "Dr. Bill needs nursing assistance in room 8." I walked in to see one nurse starting a line on her right arm, someone getting her onto the monitor, someone else getting the EKG set up...

What do you suppose was my first action? What transpired in the first few minutes? What other pieces of information do we need STAT as we talk this through?

Come play the game with me, even if you don't know the answers.

Waiting for some participants...

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Specializes in Emergency.

Gimme a big smile.

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Vitals, neuro exam, CBC? I'm not an ED nurse nor do I play one on TV. I was thinking hemorrhagic stroke based on her onset and symptoms.

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Sounds like a CVA ... she needs a scan to determine if it's hemorrhagic or ischemic? If it's ischemic assess if she's has any recent surgeries or trauma and get some TPA?

Pretty sure I'm skipping ahead!

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IV, O2, monitor, and vital signs. Collect blood for labs (CBC, chemistry, aPTT, PT). Bed side glucose.

What type of work does she do, and what exactly was she doing at time of symptom onset? Are deficits only on the face and arm or are do the affect the entire right side? What was the exact time of symptom onset?

Primary survey with emphasis on neurological evaluation. Facial symmetry, speech deficits, arm drift, gait abnormalities.

Stat non-contrasted head CT with radiologist read. Notify neurology and/or neurosurgery of possible CVA. Arrange transfer if your facility doesn’t have either neurosurgical or CVA TPA capability.

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Are lines started in affected side if it's not necessary?

I would also immediately think stroke...as the others said, neuro/vitals/CBC, how are s/sx compared to when it first started, how long has it been since symptoms started? She's only 40 so I would throw a pregnancy test in there as well. Wouldn't it have to be determined whether ischemic or hemorrhagic, which would determine treatment? Wouldn't meds she's on also be of importance (as in, if it's hemorrhagic and she's on blood thinners, something along those lines). Somewhere in the deep recesses of my brain I am thinking that there is a contrast exam in here (if so, any allergy issues) and issues with anything that would interfere with an MRI/MRA.

And Yay for another case study!!! :smug:

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Good thoughts, all...

1) First and foremost question: onset of symptoms... The risk-benefit profile for tPA is only indicated within... 3 hours from onset... though some data indicate 4.5 hours (which our docs will do, in certain cases)...

In this case, onset was 60 minutes prior to her arrival (brought in by POV)

2) Initial vitals... BP=175/105, HR=94, SpO2=100% RA, T=36.6, R=18, HA pain 6/10...

Anything of concern there?

3) Yep... neurologist at bedside doing a full assessment... in this case, a&ox4, no facial droop, no aphasia, no pronator drift, PERRL @ 3, decreased sensorium to R cheek and R arm, +5 LUE/LLE, +4 RUE/RLE

4) What other bedside evaluation needs to be done STAT?

5) Lines/labs... how many lines? what are the critical labs to draw?

~~~

Some of my questions here are being answered between the time I read and the time I post

~~~

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First thing to do check vital sign, hooked to monitor, start Iv fluids, labs

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Is it two large bore IVs? Sounds very cliché, don't know if that's it.

Labs: I agree with above users.

-CBC

-Chemistries

-Urine specimen (idk I heard that UTIs can cause strokes)

-Glucose

-APTT/PT/INR

-Cardiac enzymes

Maybe asking questions like:

Do you take any "blood thinners"?

Do you take any "medicine for your heart"?

Do you have a history of "high blood pressure"?

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Had a woman in the ED where I work with similar symptoms. She had lyme disease.

On arrival, we activated stroke alert, determined onset of symptoms, put her on the monitor, obtained vitals, drew labs, started 2 IV's, sent her to CT. Her facial symmetry was intact, neuro's intact, no new meds recently. We obtained med list, medical history, what she was doing when it started etc. Patient was a non-smoker, no blood thinners, healthy overall, no significant family history. Turned out she had been hiking recently and got bit by a tick.

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

2) Initial vitals... BP=175/105, HR=94, SpO2=100% RA, T=36.6, R=18, HA pain 6/10...

Anything of concern there?

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2) Initial vitals... BP=175/105, HR=94, SpO2=100% RA, T=36.6, R=18, HA pain 6/10...

Anything of concern there?

The diastolic is high? I mean so is systolic but diastolic worries me more.

The HA pain ... probably r/t the high BP?

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