I'm Dizzy, Tired and Can't Remember What I Ate for Lunch
A 74-year-old white male presents to the ED with confusion, fatigue, dizziness, headache and distal right arm paresthesia. Experienced nurses, model your clinical judgement skills for students and newbies by posting some priority actions.
Headache, dizziness, right distal arm paresthesia 3-4 days, confusion, recent history of mental impairment along with bradyphrenia (mild cognitive impairment or slowed thinking and processing of information).
History of Present Illness
A few months before the ED visit, I spoke with him on the phone and he said, "I'm just so tired all the time. I can't even walk across the driveway to the barn without feeling exhausted.” He finally admitted that he had stopped taking medications for hypertension and hyperlipidemia during the COVID-19 pandemic. "I just quit. I didn't feel like taking them.”
A few days ago, he told his wife he was feeling dizzy and that something was "not quite right", but he refused to go to the ED. This evening, he asked to come to the ED after experiencing increased dizziness, headache, and numbness in his hand. His wife tells the ED nurse, "He's been having a hard time remembering things.”
General Appearance
Well-developed, well-nourished, resting comfortably, breathing comfortably on room air.
Past Medical History
Hypertension, hyperlipidemia, pre-diabetes, glaucoma with ocular implants, excess EtOH consumption (greater than 2 drinks/day for men)
Family History
Father died from colon cancer at the age of 80. Mother died of cervical cancer at age 63. No siblings. One biological daughter, age 53 with no health concerns. His step-son works in the hospital and stops by during the visit.
Social History
The patient has been married to his third wife for twenty-five years. He lives on a farm and has taught at a local college for many years. This last year he has been teaching from home. His hobbies include playing the banjo and gardening. They raise llamas, so he works in the barn and fields when he isn't teaching.
Patient drinks 2-3 alcoholic beverages daily and occasionally smokes marijuana (it is legal in his state).
Medications
lisinopril-HCTZ 20-12.5 mg daily, metoprolol 25 mg BID, COSOPT, XALATAN ophthalmic, atorvastatin 80 mg. Patient states he started taking all of his medications again about two months ago.
Allergies
NKA
Vital Signs
BP 208/97 sitting, RA
Pulse rate 63
HR 56
RR 19
T 98.8o F
SpO2 98%
HT 5' 11"
WT 210 lbs
BMI 29.9
Dizziness, headache, confusion, fatigue – these are symptoms of SO MANY PROBLEMS – what else do you notice? What else would you like to know?
I've been working on preparing my students for the Next-Gen NCLEX, so I'm thinking a lot about clinical judgment and prioritization.
What's the first thing you need to do?
Is there anything emergent going on?
As the Nurse, what are your priority actions?
Since you can't post your guesses here, I'm hoping you Nurses out there will model your critical thinking by showing the students and newbies your thought process (thanks in advance!)
Specializes in Education, Informatics, Patient Safety.
Hey folks - thanks again for participating! be sure to scroll through the comments to see the FIRST FOLLOW UP.
Here is another little hint:
SECOND FOLLOW UP
CT scan wo IV contrast: Lobulated mucosal thickening and some hyperdensity in the base of the right maxillary sinus – likely chronic sinus disease. Brain ventricles normal in size and symmetric. Mastoid air cells well aerated. In the left temporal lobe, there is an area of decreased attenuation measuring 1.6 cm in diameter which is either a subacute infarction or a small tumor with peritumoral edema. No sign of intracranial hemorrhage. Calcific atherosclerotic disease of the aorta and branch vessels. Narrowing of right subclavian and mid left common carotid artery is seen.
Revealed multifocal acute left PCA territory infarcts in the left temporal lobe and medial temporooccipital region
NPO till MN for TEE to evaluate heart as potential source of emboli to brain.
Specializes in Education, Informatics, Patient Safety.
FINAL POST
An MRI with contrast and diffusion weighting revealed multiple foci of acute infarction in the left Posterior Cerebral Artery (PCA) distribution. Subacute or chronic infarct involving the anterior left temporal lobe in the left MCA distribution. No concerning signal abnormality within the brainstem.
Ischemic strokes happen when blood supply is cut off to part of the brain. This kind of stroke accounts for the majority of strokes. The blocked flow is usually caused by a clot or by atherosclerosis (narrowing of the arteries). Immediate ED treatment is critical to surviving with the least amount of damage and ability to function.
Symptoms for ischemic stroke are something we learn fairly early in our healthcare career.
Sudden numbness or weakness of the face, arm or leg, especially on one side of the body
Sudden confusion
Sudden trouble speaking
Sudden trouble seeing in one or both eyes
Sudden trouble walking
Sudden dizziness, loss of balance or coordination
Sudden, severe headache with no known cause
See the reference for additional symptoms seen in women.
With this patient, not all symptoms of stroke occurred and the symptoms went away fairly quickly; however, they may return. When symptoms clear up with minutes this may be a sign of a transient ischemic attack – one of the early warning signs of a stroke.
Risk factors: being male (though more women die of stroke), smoking, personal history of stroke or MI, African American race, uncontrolled hypertension, diabetes, CAD and high blood cholesterol are additional risk factors. Stroke can also be caused by problems with the heart like arrhythmias, heart valves, infections, inflammation, blood clotting disorders or MI.
Stroke diagnosis involves CT and MRI, EEG and blood flow tests like TEE.
If treatment is sought within the first three hours after symptoms begin, the patient might get tPA to dissolve the clot – increasing the chance of full recovery. Stenting for blockages may also occur. The goal of treatment is to prevent complications, future strokes, reduce disability and regain normal function.
The atypical nature of this stroke was discussed with the family, and they were told to seek treatment sooner if symptoms return.
I spoke to the patient several days after DC and he was still having word finding difficulty. He stated he was giving up drinking and taking his medications as ordered. His son reported that he continues to have issues with recall. He did decide to finally retire from teaching, which has made his family very happy!
SafetyNurse1968, BSN, MSN, PhD
60 Articles; 529 Posts
Hey folks - thanks again for participating! be sure to scroll through the comments to see the FIRST FOLLOW UP.
Here is another little hint:
SECOND FOLLOW UP
CT scan wo IV contrast: Lobulated mucosal thickening and some hyperdensity in the base of the right maxillary sinus – likely chronic sinus disease. Brain ventricles normal in size and symmetric. Mastoid air cells well aerated. In the left temporal lobe, there is an area of decreased attenuation measuring 1.6 cm in diameter which is either a subacute infarction or a small tumor with peritumoral edema. No sign of intracranial hemorrhage. Calcific atherosclerotic disease of the aorta and branch vessels. Narrowing of right subclavian and mid left common carotid artery is seen.
Revealed multifocal acute left PCA territory infarcts in the left temporal lobe and medial temporooccipital region
NPO till MN for TEE to evaluate heart as potential source of emboli to brain.
Transesophageal Echo (TEE)/echocardiogram: moderate immobile atherosclerosis
EEG: normal EEG during wakefulness and sleep, no epileptiform activity during recording
ECG: normal