iHuman Case Study Week 10: Brad Banerjee, 31 Y/O MALE CC: Untreated Hypertension| SOLVED, Exams of Nursing

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iHuman Case Study Week 10: Brad Banerjee,

31 Y/O MALE CC: Untreated Hypertension

WK 10 – Neuro/Ortho/Plastics/Reconstructive Sx – Brad Banerjee 31 Y/O C/O: Acute dizziness, HA, and unsteady gait HPI: This is a 31 year old male with a past medical history significant for untreated hypertension for 2 years, a recent smoker who quit 2 weeks ago and 2 days ago visited the ED with a right-sided headache and vertigo symptoms with Excedrin and Tylenol as the treatment plan for which he states has not helped. He presents today with the chief compliant of a sudden onset, deep, sharp- like pain right-sided headache rated 6/10. He denies a history of migraines and in fact a history of any types of headaches. He states he rarely has headaches and has never had a headache like this before. This began 2 days ago while sitting at his desk at work when he felt this sharp pain suddenly. He also states when he stood up from his desk the “room was spinning” or he was spinning” and had to sit back down to keep from falling. The onset of vertigo began immediately after he felt the sharp pain in his head and has been constant ever since. He states moving his head and standing makes it worse and lying down and not moving makes it a little better. Yesterday he noticed a gradual onset of double vision which has not changed since it has started. He has moderate nausea that started around the same time as the other complaints did 2 days ago, however he denies vomiting. Also, last night he started hiccupping and it has not stopped. He has noticed that over the course of the past 2 days the right side of his face and left hand “feels strange” and his left leg “feels heavy”. He states he cannot walk without help, he stumbles from side to side, and he is consistently falling to the left side. Problem Statement: This is a 31 year old male with a past medical history significant for untreated hypertension for 2 years, a recent smoker who quit 2 weeks ago and 2 days ago visited the ED with a right-sided headache and vertigo symptoms with Excedrin and Tylenol as the treatment plan for which he states has not helped. He presents today with the chief compliant of a sudden onset, deep, sharp- like pain right-sided headache rated 6/10. This began 2 days ago while sitting at his desk at work when he felt this sharp pain suddenly. He also states when he stood up from his desk the “room was spinning” or he was spinning” and had to sit back down to keep from falling. Other HPI complaints: Nausea; decreased appetite; right-side face and hand feels "strange; left- leg heaviness-having trouble walking; hiccups PE: pink conjunctiva, nystagmus, + romberg test, sitting ataxia-falling to the right PE-CHART eyes: nystagmus noted, conjunctiva pink, sclerae non-icteric, pupils equal round and reactive to light and accommodation, no drainage or discharge Musc: moves all extremities, normal bulk and tone, no rigidity, normal stability, asymmetric strength, weak left hand grip and left leg raise Neuro: Awake, alert, and fully oriented, cranial nerves I-XII intact, sensory grossly normal to touch and pin prick, deep tendon reflexes symmetrical 2+ throughout, no involuntary movements noted; broad-based stance & gait w/ falling toward right and sitting ataxia with falling to the right noted, + romberg's test

from PCP and maintain a journal of daily blood pressures to take with him to adjust the thiazide medication as well. He will also be started on Rivaroxaban for anticoagulation for prevention of another clot as well as daily ASA (Porter et al., 2018). Patient will also most likely require PT and OT outpatient several times a week. Lifestyle modifiers will be provided in education to the patient. Status/Condition: Guarded Code Status: Full Allergies: NKDA Admit to Unit: Neuro-Surgical ICU Activity Level: Strict bedrest; minimize stimuli, HOB elevated >30º at all times to ensure optimal venous drainage. Diet:

1. NPO – until decision is made about surgical intervention
2. Low +Na Clear Liquid diet in anticipation of possible surgical intervention due to likely complications that occur within 5 days after PICA stroke (Kondziella et al., 2013; Neugebauer et al., 2013)
3. Regular 1.5 gm/d sodium restricted diet Medications: all NOW doses given in ER (HOLD ALL PO DOSES WHILE NPO) Zofran 4 mg IVP NOW, then q6h PRN for nausea Morphine 1 mg IVP NOW for headache; If not relieved increase to 2 mg IVP q4h PRN Aspirin 325 mg po once daily; (Papadakis et al., 2018) Rivaroxaban 20 mg po once daily The main advantage is the ease of use (e.g., no need to check anticoagulation level with blood test after initial dose or to use a parenteral or subq anticoagulant such as heparin) (Porter et al., 2018). This medication is a direct factor X inhibitor. Furosemide 20 mg IVP q6h prn for edema/ICP – Furosemide - is used in the acute setting for reduction of increased ICP & suppression of cerebral sodium uptake (Arcangelo & Peterson, 2013). Mannitol 1 g/kg IV, followed by 0.25 g/kg IV every 4 hours PRN as needed for increased ICP Docusate Sodium 100 mg po twice daily stool softeners are given to prevent Valsalva maneuvers with resultant peaks in SBP and ICP (Arcangelo & Peterson, 2013). Hydrochlorothiazide 12.5 mg po daily

Lipitor 20 mg po daily Pantoprazole 40 mg IVP NOW daily for PUD prophylaxis IVFs: 3% NaCl @ 75 ml/hr NOW has similar indications and efficacy to mannitol but is another tool to help reduce or minimize ICP (Arcangelo & Peterson, 2013; Porter et al., 2018 ). Drips: Only if SBP exceeds 220: Labetalol 2 mg/kg/hr / NS 250 ml IVPB intravenous continuous infusion. Titrate to maintain a SBP of 170-200 mmhg for the first 72 hours, then after titrate to maintain 140/90 mmhg (Arcangelo & Peterson, 2013; Papadakis et al., 2018). Labetalol – intravenous beta-blockers, which have a relatively short half-life, can be titrated easily and do not increase intracranial pressure (ICP) (Arcangelo & Peterson, 2013). Propofol initial: 5- 70 mcg/kg/hr IV infusion; Titrate to a rass score – 1; d/c when extubated Antibiotics: Respiratory: O2 @ 2L/min BNC PRN; titrate to maintain O 2 saturation > 95% Ventilator AC 14/450/100%/5; titrate to maintain O 2 saturation > 95% required for surgery/ extubate in pacu OR if patient decompensates in ICU Nursing Orders: continuous cardiac and pulse oximetry monitoring, temperature q4h, blood pressure checks q minutes for 2h then q1h after; Arterial BP monitoring; CVP monitoring (8); 16F Foley with hourly I&Os; Neuro checks q2h; Bedside Glucose Stick q6h Minimize stimuli, HOB elevated >30º at all times to ensure optimal venous drainage. Sequential Compression Device (SCDs) continuous Insert NGT if patient is intubate; connect to LIS; Administer daily medications via NGT, clamping afterwards.

your risk of atherosclerotic plaque and blockages increases. You actually have both problems which is why you have been prescribed Lipitor 20 mg daily Rivaroxaban is used to prevent blood clots from forming by blocking certain clotting proteins in your blood. You are taking this drug to prevent future strokes and blood clots and the dose should be taken once a day with the evening meal. Do not increase your dose (if you miss a dose), take it more often, or stop taking it unless you are told to do so by your doctor. If you are unable to swallow whole tablets, you may crush the tablet and mix it with applesauce. Eat the entire mixture right away. Do not prepare a supply for future use. This medication can cause serious bleeding if it affects your blood clotting proteins too much. Tell your doctor right away if you have any signs of serious bleeding, including: unusual pain/swelling/discomfort, unusual bruising, prolonged bleeding from cuts or gums, persistent/frequent nosebleeds, unusually heavy/prolonged menstrual flow, pink/dark urine, coughing up blood, vomit that is bloody or looks like coffee grounds, severe headache, dizziness/fainting, unusual or persistent tiredness/weakness, bloody/black/tarry stools, difficulty swallowing Stroke – You had a stroke most likely due to a combination of untreated hypertension, hyperlipidemia, smoking history, and family history. The above lifestyle modifications and medications are paramount in avoiding a future stroke and certain cardiovascular disease. Signs and symptoms of a stroke to watch for are vision changes, confusion, slurred speech, headache and weakness on one side of the body. You will need to possibly attend PT and OT outpatient several times a week. The length of time is really not known. It could be several months or a year and sometimes the deficits are never recovered. Discharge planning and required follow-up care: Follow-up with PCP for bloodwork 2 - 4 weeks after discharge for evaluation of new medication (titration of Hydrochlorothiazide and Lipitor) Follow-up with Neurology one week for discharge Follow-up with Neurosurgery 2 - 4 weeks from discharge PT and OT outpatient several times a week New Prescriptions: Hydrochlorothiazide 12.5 mg po daily Lipitor 20 mg po daily Rivaroxaban 20 mg po once daily Aspirin 81 mg po once daily References Arcangelo, V. & Peterson, A. (Eds.). (2013). Pharmacotherapeutics for advanced practice: A practical approach (3rd ed.). Ambler, PA: Lippincott Williams & Wilkins

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