cva case pres

7/27/2019 CVA Case Pres

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Patients BackgroundPersonal Data

Name of Patient: Mr. X

Age: 64 y/o

Status: Married

Sex: Male

Admitting Diagnosis :T/C Sepsis S/S CVA

Final Diagnosis :CVA ( Cerebrovascular Accident)

Past Medical History :Hypertension, DM Type II

Vital Signs :BP = 130/80 ; PR = 72 ; RR = 22 ;

T = 37.5 C

Brief History:

The patient has been bedridden since he had stroke last April 2007, he also

had difficulty in swallowing and have a necrotic ulceration at the sacrum and

olecranon prior to admission. Mr. Ex-Men had a sedentary lifestyle, he loves eating

fatty foods and food with high calories, he also have a family background on

hypertension. He only stays at home and doesnt exercise. In 1987, he also had

stroke due to hypertension, but didnt take any maintenance drug after that. He

only takes Calcibloc 10mg, whenever he feels the signs and symptoms ofhypertension.

Review of Systems

- Physical Assessment

Vital signs : T 37.5 C PR 72 RR 22 BP 130/80

Consciousness : obtunted open eyes, responds slowly, confused

Bed-ridden

Hemi paresis - left side of the body

Wt: 47 kgs. Ht: 5 5

Weight ( loss [+] gain [ - ] ) Fever [ - ] Night Sweats [ - ]

Significance: weight loss of about 4-5 kgs.


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SKIN

Change in color [ - ] , Ulcers [ + ] ,Rashes [ - ] , Pruritus [ - ] , Bruising

[ - ] ,

Nevi ( change in color [ - ] / shape [ - ] / size [ - ] )

Significance: Sacrum - stage 3 decubitus ulcer (ulcer extends to

subcutaneous fat layer) , Olecranon process of ulna stage 2 decubitus

ulcer (skin is broken to epidermis, abrasion and blister present)

Oxygen is given via nasal canula at 2-3 lpm to deliver more oxygen to

blood

enhance wound healing

HEAD

Headache [ - ] , Injury [ - ] , Tenderness [ - ]

Hair & scalp condition ( infection/ infestation) [ - ], texture silky [ - ] ,

oily [ + ]

Significance: oily hair need to improve hygiene

EYES

Change in visual field [ - ] , Glasses [ - ] , Diplopia [ - ] , Inflammation [

- ] ,

Discharge [ - ]

Significance: none

NOSE

Allergies [ - ] , Sinus problem [ - ] , Obstruction [ - ] , Polyps [ - ] ,

Discharge [ - ], Epistaxis [ - ]

Significance: none

Throat

Toothaches [ - ] , Loose teeth [ - ] , Dentures [ - ] , Bleeding gums [ - ] ,

Mouth sores [ - ] , Difficulty in swallowing [ + ] , Ulceration or lesion on


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tongue, gums, buccal mucosa [ - ]

Significance: NG tube feeding

Respiratory

Chest pain [ - ] , Dyspnea [ + ] , Cough [ - ] , Amount and color of

sputum

[ - ] , Hemoptysis [ - ]

Significance: Ventilation machine

Oxygen is given via nasal canula at 2-3 lpm to ease labored breathing

Cardiovascular

Chest pain / pressure / tightness [ - ] , Orthopnea [ + ] , Claudication [ -

]

Significance: Bed reclined to ease breathing

Gastro-Intestinal

Dysphagia( solid & fluid ) [ + ] , Ulcer [ - ] , GERD [ + ] , Indigestion [ - ]

,

Diarrhea, Constipation [ - ] , Blood in stool [ - ] , Hemorrhoids [ - ],

Jaundice [ - ]

Significance: NG tube feeding

Genito-Urinary

Dysuria / Hematuria / Nocturia [ - ] , UTI [ - ] , Incontinence [ +/- ]

Significance: Bed reclined to ease breathing

Endocrine

Heat / Cold tolerance [ - ] , Weight change [ + ] , Polydisia [ - ] ,

Polyuria [ - ] ,


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Polyphagia [ - ]

Significance: Weight loss of about 4-5 kgs.

Musculo-Skeletal

Limitation of movement [ + ] , Stiffness [ - ] , Joint swelling/redness [ - ]

,

Arthritis [ - ] , Muscle spasm [ - ] , Muscle weakness [ + ]

Significance: Hemi paresis left side of the body

Psychiatric

Mood change [ - ] , Anxiety [ - ] , Suicidal thoughts/ attempts [ - ]

Significance: none

Laboratory Results

Hematology Report

Normal Values Results

emoglobin M 140 170 g/LF 120 160 g/L

96

ematocrit M 0.42 0.52F 0.37 0.470.28

ed Blood Cells Count (RBC) M 4.5 5.5 x 1012/LF 4.0 5.2 1012/L

2.73

hite Blood Cells Count (WBC) 4 10 x 109/L 15.5

atelet Count 150 400 x 109/L 395

hers:

fferential Count

gmenters 0.50 0.70 0.93

ymphocytes 0.20 0.40 0.05

onocytes 0.02 0.07 0.02


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Clinical Chemistry Report

Normal Values R

Creatinine B2 M 80 115 umol/LF (53-97)

1

SGPT B2 0 41 u/L 5

Total CHON B2 65 80 g/L 6

Albumin B2 35 50 g/L 3

Globulin B2 15 35 g/L 3

Cholesterol B2 3.6 6.5 mmol/L 2

Triglycerides B2 0.4 1.86 mmol/L

HDL B2 > 0.90 mmol/L 0

LDL B2 < 3.4 mmol/L

VLDL B2 0.18 0.84mmol/L 0

DRUG STUDY

NAME OF DRUG/

GENERIC NAME

INDICATION AND

DOSAGE

ACTION SIDE EFFECTS


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Name of Drug:

TAZOCINCommon Name:

2.25 g vial

Piperacillin Na 2 g

Tazobactam Na 250 mg4.5 g vial

Piperacillin Na 4 g

Tazobactam Na 500 mg

Indication:

Treatment of Systemic andor local bacterial

infections caused by

sensitive organisms;

UTI, lowerrespiratory tract,

intra-abdominal; skin

and skin structureinfections; bacterial

septicemia;

polymicrobicinfections.

Dosage:

Adult & Children > 12yr.

2.25-4.5 g/day 6-8

hours or 12 hourly byIM or IV infusion

(.20-30 min)

Penicillins are usually

bactericidal in action.They bind reversibly

to several enzymes

outside the bacterial

cytoplasmicmembrane. These

enzymes, known as

penicillin-bindingproteins (PBPs) are

involved in cell-wall

synthesis and celldivision.

Interference with

these processes

inhibits cell-wall

synthesis, causingrapid destruction of

the cell.

Diarrhea, constipation,

nausea, headache,insomnia, rash,

erythema, pruritus

vomiting, allergic

reactions, urticariaand super infection

NAME OF DRUG/

GENERIC NAME

INDICATION AND

DOSAGE

ACTION SIDE EFFECT

Name of Drug:

DUAVENT

Common Name:Per 2.5 ml pulmoneb

Ipatropium Br 500 mcg

Salbutamol sulfate 2.5mg

Indication: Bronchodilator

for treatment of

bronchospasmassociated with

COPD, including

chronic bronchitis,emphysema and

asthma

Dosage:

1-2 pulmoneb every 6-8hours

Inhibits vagally mediated

reflexes by

antagonizingacetylcholine

CNS nervousness,

dizziness, head

Cardiovascular palpitations

EENT blurred visio

epistaxisGI nausea, GI distr

dry mouth

Respiratory cough,

respiratory tracinfection, bronc

bronchospasm

Skin - rash


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NAME OF DRUG/

GENERIC NAME

INDICATION AND

DOSAGE

ACTION SIDE EFFECTS

Name of Drug:

AEKNILCommon Name:

Paracetamol

Indication:

Pyrexia of unknown origin.Fever and pain

associated with

common childhooddisorders, tonsillitis,

upper respiratory tract

infections, postimmunization

reactions, after

tonsillectomy andother conditions.

Prevention of febrileconvulsion.

Headache, cold,sinusitis, muscle pain,

arthritis and

toothache.Dosage:

2-3ml depending on the

severity of case, dosemay be repeated 4

hourly. In severe of

cases, dose may beadministered by IVvery slowly

May produce analgesic

effect by blockingpain impulses by

inhibiting

prostaglandin or painreceptors sensitizers.

May relieve fever by acting

in hypothalamus heat-regulating center

Hematologic hemo

anemia, neutropleucopenia,

thrombocytope

Hepatic liver dama(with toxic dos

jaundice

Metabolic

hypoglycemia

Skin rash, urticaria

Anatomy & Physiology

Lobes of the Brain


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The manifestations of stroke depend on which region and the extent of brain

affected.

The three main components of the brain:

Cerebrum - the largest and most developmentally advanced part of the

human brain. It is responsible for several higher functions, including higher

intellectual function, speech, emotion, integration of sensory stimuli of all

types, initiation of the final common pathways for movement, and fine control

of movement.

Cerebellum - second largest area, is responsible for maintaining balance and

further control of movement and coordination.

The brain stem is the final pathway between cerebral structures and the

spinal cord. It is responsible for a variety of automatic functions, such as

control of respiration, heart rate, and blood pressure, wake-fullness, arousal

and attention.

Cerebrum is divided into a right and a left hemisphere and is composed of

pairs of frontal, parietal, temporal, and occipital lobes.

The left hemisphere controls the majority of functions on the right side of the

body, while the right hemisphere controls most of functions on the left side of

the body The crossing of nerve fibers takes place in the brain stem. Thus,

injury to the left cerebral hemisphere produces sensory and motor deficits on

the right side, and vice versa.

Cerebellum and Brainstem

A stroke involving the cerebellum may result in a lack of coordination,

clumsiness, shaking, or other muscular difficulties. These are important to

diagnose early, since swelling may cause brainstem compression or

hydrocephalus

Strokes in the brainstem are usually due to basilar occlusion, although in

many cases the clinical syndrome may fit the criteria for a lacunar stroke.

Brainstem strokes can be serious or even fatal. People who survive may be

left with severe impairments or remain in a vegetative state.

Major Blood Vessels

Normal function of the brain's control centers is dependent upon adequate

supply of oxygen and nutrients through a dense network of blood vessels.


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Blood is supplied to the brain, face, and scalp via two major sets of vessels:

the right and left common carotid arteries and the right and left vertebral

arteries.

The common carotid arteries have two divisions.

The external carotid arteries supply the face and scalp with blood.

The internal carotid arteries supply blood to the anterior three-fifths of

cerebrum, except for parts of the temporal and occipital lobes.

The vertebrobasilar arteries supply the posterior two-fifths of the cerebrum,

part of the cerebellum, and the brain stem.

Any decrease in the flow of blood through one of the internal carotid arteries

brings about some impairment in the function of the frontal lobes. This

impairment may result in numbness, weakness, or paralysis on the side of

the body opposite to the obstruction of the artery. Occlusion of one of thevertebral arteries can cause many serious consequences, ranging from

blindness to paralysis.

Circle of Willis

At the base of the brain, the carotid and vertebrobasilar arteries form a

circle of communicating arteries known as the circle of Willis.

From this circle other arteries -- the anterior cerebral artery (ACA), the

middle cerebral artery (MCA), the posterior cerebral artery (PCA) - arise and

travel to all parts of the brain. Posterior Inferior Cerebellar Arteries (PICA),which branch from the vertebral arteries, are not shown.

Because the carotid and vertebrobasilar arteries form a circle, if one of

the main arteries is occluded, the distal smaller arteries that it supplies can

receive blood from the other arteries (collateral circulation).

Anterior Cerebral Artery

The anterior cerebral artery extends upward and forward from the

internal carotid artery. It supplies the frontal lobes, the parts of the brain that

control logical thought, personality, and voluntary movement, especially the

legs. Stroke in the anterior cerebral artery results in opposite leg weakness.

If both anterior cerebral territories are affected, profound mental symptoms

may result (akinetic mutism).

Middle Cerebral Artery

The middle cerebral artery is the largest branch of the internal carotid.

The artery supplies a portion of the frontal lobe and the lateral surface of the


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temporal and parietal lobes, including the primary motor and sensory areas

of the face, throat, hand and arm and in the dominant hemisphere, the areas

for speech. The middle cerebral artery is the artery most often occluded in

stroke.

Posterior Cerebral Artery

The posterior cerebral arteries stem in most individuals from the basilar

artery but sometimes originate from the ipsilateral internal carotid artery.

The posterior arteries supply the temporal and occipital lobes of the left

cerebral hemisphere and the right hemisphere.

When infarction occurs in the territory of the posterior cerebral artery, it

is usually secondary to embolism from lower segments of the vertebral

basilar system or heart.

Clinical symptoms associated with occlusion of the posterior cerebralartery, depend on the location of the occlusion and may include thalamic

syndrome, thalamic perforate syndrome, Weber's syndrome, contralateral

hemiplegia, hemianopsia and a variety of other symptoms, including color

blindness, failure to see to-and-fro movements, verbal dyslexia, and

hallucinations. The most common finding is occipital lobe infarction leading to

an opposite visual field defect.

Lenticulostriate Arteries

Small, deep penetrating arteries known as the lenticulostriate arteries

branch from the middle cerebral artery Occlusions of these vessels orpenetrating branches of the circle of Willis or vertebral or basilar arteries are

referred to as lacunar strokes. About 20% of all stokes are lacunar and have a

high incidence in patients with chronic hypertension and in the elderly CT

scanning shows signs of infarction in only approximately half of the most of

the common form of lacunar stroke (pure motor stroke), but MRI has

increased the yield

Pathophysiology

1.Disruption of blood to a part of the brain

2.Oxygenation of Neurons reduced

3.Anaerobic glycolysis

4. Sodium pump & neurotransmitter fail

5. Cerebral edema


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6. Cerebral blood Vessel walls swell; Circulation is compromised and vasospasm

combined with blood viscosity reduced cerebral perfusion

7. Outcomes of decreased cerebral perfusions: cerebral anoxia; cerebral

infarction; contralateral deficits; permanent deficit

Types of Stroke:

(1) Ischemic Stroke

Transient ischemic Stroke (TIA) - is a short-term stroke that lasts for less

than 24 hours. The oxygen supply to the brain is restored quickly, and

symptoms of the stroke disappear completely. A transient stroke needs

prompt medical attention as it is a warning of serious risk of a major stroke

Cerebral thrombosis occurs when a blood clot (thrombus) forms in an

artery (blood vessel) supplying blood to the brain. Furred-up blood vessels

with fatty patches of atheroma (arteriosclerosis) may make a thrombosismore likely. The clot interrupts the blood supply and brain cells are starved of

oxygen.

Cerebral embolism is a blood clot that forms somewhere in the body

before travelling through the blood vessels and lodging in the brain. This

causes the brain cells to become starved of oxygen. An irregular heartbeat or

recent heart attack may make you prone to forming emboli.
http://www.netdoctor.co.uk/diseases/facts/atherosclerosis.htmhttp://www.netdoctor.co.uk/diseases/facts/coronarythrombosis.htmhttp://www.netdoctor.co.uk/diseases/facts/atherosclerosis.htmhttp://www.netdoctor.co.uk/diseases/facts/coronarythrombosis.htm


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(2) Hemorrhagic Stroke - occurs when a blood vessel bursts inside the brain andbleeds (hemorrhages). With a hemorrhage, extra damage is done to the brain tissue

by the blood that seeps into it..

Signs and Symptoms of CVA

Altered consciousness or unconsciousness

stertorous breathing

Unequal pupils ( larger pupil noted on same side as stroke)

Paralysis of one side

Perspiration

Aphasia (abnormal or absent of speech)

Blank stare

Dysphagia

Inability make decisions


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Loss of memory

Gait instability

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