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.
The blood pressure is concerning, as is the headache. Does she have a history of hypertension? If so, is she compliant with her treatment what is her baseline BP? How does she describe the headache? History of headaches? Was it sudden in onset with the remaining symptoms? Any associated symptoms? Nausea/vomiting? Visual disturbances? Neck stiffness?
Is the right sided deficit improving, worsening, or unchanged? Would hold oxygen as long as the SpO2 is 100%. If it drifts would add supplemental oxygen to maintain ≥95%.
I agree with StudentofHealing, a baseline set of cardiac enzymes wouldn't hurt.
She still needs the CT scan. If she is having a CVA, with the hypertension and blood pressure I would suspect it's hemorrhagic, although even if it were an ischemic CVA I doubt that she would be a TPA candidate based upon blood pressure and the relative symptomology.
BP is of concern, if I recall correctly >150/100 increase risk of second stroke. HA pain as well...worst headache ever?? Sudden? What type of pain? HR I would watch as well since it's on the high end of normal (whenever I see changes in HR I think of compensation for maintaining CO, so that's why I'd keep an eye on it, even though it's in normal range)
The BP combined with the heart rate and headache make me think increased ICP, possibly first stage of Cushing's triad. But why is the ICP elevated? Get any labs or tests back yet?
Editing to add that I've been sitting here on my tablet reading through the responses and talking out loud to my husband. He's alternating between watching the Blue jays/Yanks game and being entertained by me talking through this scenario.
Yes HTN and sudden HA are of concern and are suggestive of SAH. We could also evaluate hx of TIA, hx of trauma however minimal, is she diabetic, hx of arrythmias or valvular disease?
Same type of patient came into the ER where I worked. I got vitals, started IV's. drew labs, EKG, med and medication history taken.
Doctor delayed seeing the patient while playing on the computer ignoring my plea to see the patient. She started projectile vomiting after being in the ER for 45 minutes, became unconscious. Was rushed for a CT scan. Had a brain bleed. Died the next day at 52 years old. Vital signs and symptoms should help with progression of medical testing needed. I always prepare for the worst and hope for the best.
chare
4,372 Posts
The blood pressure is concerning, as is the headache. Does she have a history of hypertension? If so, is she compliant with her treatment what is her baseline BP? How does she describe the headache? History of headaches? Was it sudden in onset with the remaining symptoms? Any associated symptoms? Nausea/vomiting? Visual disturbances? Neck stiffness?
Is the right sided deficit improving, worsening, or unchanged? Would hold oxygen as long as the SpO2 is 100%. If it drifts would add supplemental oxygen to maintain ≥95%.
I agree with StudentofHealing, a baseline set of cardiac enzymes wouldn't hurt.
She still needs the CT scan. If she is having a CVA, with the hypertension and blood pressure I would suspect it's hemorrhagic, although even if it were an ischemic CVA I doubt that she would be a TPA candidate based upon blood pressure and the relative symptomology.