subarachnoid hemorrhage

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subarachnoid hemorrhage

Case Study 1

Chief Complaints

Provided by husband: “My wife vomited then fainted in the bathroom at home and I couldn’t wake her up”

HPI

Maria Estrada is a 62 y/o right-handed Hispanic female who collapsed in her bathroom after vomiting at 4am today. Paramedics report that she was unresponsive with minimally reactive pupils and her breathing was labored. She was intubated for airway protection and brought to the ER. Glasgow Coma Scale is 4 on arrival, and BP on admission was 202/128. A head CT revealed a subarachnoid hemorrhage, and a cerebral angiogram was negative for source. Of note, husband states that patient had been complaining of a headache for the last 3 days.

PMH

– Patient had not seen a doctor for over 30 years until 2 months ago, when she presented to the ER with respiratory distress. On that admission, the patient was diagnosed with a left femoral DVT and a pulmonary embolus. The patient was also diagnosed with Type 2 diabetes, hypertension, and hyperlipidemia. She was started on multiple medications and given instructions for follow-up, but has not followed up due to lack of insurance. Husband reports that the patient has continued to take the medications she was prescribed as they ordered these medications through a friend in Mexico. subarachnoid hemorrhage

FH

– 2 siblings with HTN and DM

– Mother and father deceased in their 60s, unknown causes

SH

– Married for 43 years, 4 adult children and many grandchildren

– Had been working part time as a hairdresser-has not worked since hospitalization 2 months ago

– No history of alcohol, smoking, or recreational drug use

– Patient is undocumented and has no insurance subarachnoid hemorrhage

Home Medications

– Warfarin 5mg QD

– Simvastatin 20mg qHS

– Metformin 500mg BID with morning and evening meals

– Lisinopril 10mg QD

Allergies

– NKDA

PE and Lab Tests

Gen

– The patient is intubated and unresponsive subarachnoid hemorrhage

Vital Signs

– BP 188/98

– P 92, regular

– RR – 12, ventilator controlled

– T 98.2 F

– Ht 5’3”

– Wt 165 lbs

– O2 sat 96% on 24% O2 per vent

Skin

– Warm, dry, well perfused with normal turgor

– Multiple bruises on lower legs

– No rashes or breakdown subarachnoid hemorrhage

HEENT

– (-) bruises, masses, and deformities on head

– Pupils non-reactive

– (+) papilledema

– TMs clear and intact

– Oropharynx pink, clear, moist without erythema or lesions

Neck

– Supple

– (-) for thyromegaly, JVD, and carotid bruits, adenopathy

Lungs/Thorax

– Lungs CTA bilaterally

Cardiac

– RRR, normal S1 and S2, no S3 or S4

Abd

– Obese, soft

– BS x 4

– (-) palpable masses, bruits subarachnoid hemorrhage

GU

– Deferred

MS/Ext

– (-) cyanosis, clubbing, edema

– Pulses 2+ throughout

Neuro

– AO x 0, comatose

– (-) gag reflex

– (-) corneal reflex

– Hyperreflexia on right side

– (+) Babinski on right

– (+) decorticate posturing in response to painful stimuli (sternal rub)

Laboratory Results

Na 136 mEq/L

WBC 5,700 /mm3 subarachnoid hemorrhage

K 3.8 mEq/L

PT 110 sec

Cl 101 mEq/L

PTT 45.1 sec

BUN 14 mg/dL

Albumin 4.2 g/dL

Cr 1.0 mg/dL

Ca 8.9 mg/dL

Glucose 212 mg/dL

INR 3.2

Hgb 14.0 g/dL

A1c 9.5

Hct 40 %

Case Study #1 Questions

1. Compare and contrast ischemic and hemorrhagic strokes. Which type of stroke has this patient had? What signs and symptoms are present? (2 points)

2. What are the patient’s risk factors for stroke?

3. What is that Glasgow Coma Scale? Is the patient’s score of 4 on admission good or bad? subarachnoid hemorrhage

4. For each of the patient’s prescribed medications, provide the class, mechanism of action, side effects, and the reason that this patient is taking the medication (2 points)

5. For each abnormal lab value, provide the normal value and a rationale for why there is an abnormal value for this patient. (2 points)

6. After admission, the patient is prescribed nimodipine and levetiracetam in addition to her home meds. Explain the mechanism of action and side effects for these medications, and explain why these were added for this patient.

7. 2 days after admission, patient’s ICP is 22 and her MAP is 80. What is her CPP? Is this good or bad? If we cannot lower the patient’s ICP, how could we increase her CPP? (2 points)

8. 3 days after admission, the patient’s urine output increases to 4000ml for the day. Her Na level is taken and it is 152 mEq/L. What is the likely cause of this?

9. 4 days after admission, the patient’s NIH Stroke Scale is 22. Briefly describe the NIH Stroke Scale, and what a score of 22 means. subarachnoid hemorrhage

10. 6 days after the stroke, the patient begins to show deteriorating neurologic status. An angiogram is performed which demonstrates cerebral vasospasm. Provide and explanation of vasospasm.

11. 2 weeks after the stroke, the patient continues to have right sided weakness as well as garbled speech. Which cerebral artery do you think was affected based on these symptoms? Specify right or left side.