Clinical Reasoning Report For Emergency Department: A Case Study

Consider the patient Situation

Discuss about the Clinical Reasoning Report for Emergency Department.

The patient named Mrs. Amari, who is 59-years-old has been admitted in the emergency department after the sudden slurring of speech and drooping of face on one side, which was noticed by her husband. Her medical history reveals that she has hypercholesterolemia and hypertension. She has a history of using tobacco for about 25 years but ten years ago, she quitted this habit. Her husband smokes one pack of cigarette every day. The patient also has a family history of cardiovascular disease. She walks with her friends in the neighbourhood occasionally and she does not exercise regularly. Her husband is in good health and can perform his work independently every day. She has been marred since 26 years and has two daughters living in another state.

Considering the culture and lifestyle of Mrs. Amari, she is an old New Zealand Maori lady. According to the culture and lifestyle of the Maoris, they are hard working as they believe in hunting and collecting their food. Being from the indigenous Polynesian community of New Zealand, she is expected to follow a lifestyle filled with physical activities (Nairn et al. 2014). According to the Maori culture, she should be adapted to base her diet on seafood and birds with no inclusion of junk food. Smoking is in the culture of the Maoris that causes several diseases and she has a long history of smoking, although she is out of smoking since past ten years (Castro et al. 2013). She is physically built for the indigenous activities like hunting but she rarely had any physical activity except occasional walks in the neighbourhood with friends without any inclusion of exercises. Since there was a drift in the culture and lifestyle of a Maori lady to a non Maori type, this can be a contributory factor for the mini stroke that she suffered and affected her health.

Patient’s Magnetic Resonance Imaging is normal and her head computed tomography scan reveals no acute intracranial change. She has been transferred to the stroke unit from the emergency department and will be provided care by the neurologist and she will be diagnosed for mini stroke or transient ischaemic attack (TIA). Her presentation to a facility adds to the context of the situation as the diagnosis of her presentation relies profoundly on the health history and physical examination skills of the healthcare professionals within the facility.

Collect Cues and information

In the given case scenario, there is a possibility that the patient has encountered a mini stroke or transient ischaemic attack since the patient felt numbness on the right side of face and in right arm as well. A temporary disruption in the blood supply to the brain part results in transient ischaemic attack (Sposato et al. 2015). The disruption occurs due to the lack of oxygen supply to the brain and can result in developing sudden symptoms that are similar to that of a stroke, like lack of sensation or numbness in the face, arms and legs (Merwick et al. 2010). In addition, there is a drooping of face on one side. Besides this, there are some other symptoms like disturbance in vision and speech. The time for the blockage is short in the condition hence no permanent damage occurs (Galvin et al. 2014). In the given case study, it is evident that when the patient was shifted to the stroke unit from the emergency department, her symptoms got resolved and she had no complaints regarding numbness.  

There is a high possibility of encountering transient ischaemic attack in the individuals having hypertension (Rothwell, Algra and Amarenco 2011). In the given case study, the patient has a history of hypertension, so it can be expected that she had encountered transient ischaemic attack.  She also use used to smoke in the past, which might have acted as a factor of risk to encounter transient ischaemic attack. TIA is diagnosed usually through physical exam and reviewing the patient history. It differs from Cerebrovascular accident (CVA), which is more life threatening (Compter et al. 2014). In this condition, a permanent blockage occurs in the brain’s nerves that results due to a moving blood clot, consisting of fats (Kernan et al. 2014). The persons suffering from hypertension are highly prone to encounter stroke. Conversely, TIA is less risky and occurs due to oxygen disruption in the brain and therefore a temporary consciousness leading to emergency conditions (Khan and Shuaib 2014). Several radiological tests are performed to evaluate the occurrence of TIA. The tests such as ultrasound for the neck and echocardiogram for heart and MRI for the brain can be performed (Everson-Rose et al. 2014).

Interpret – After the drooping of face on one side and sudden slurring of speech, the patient was presented in the emergency department of the hospital, where she was alert and oriented. For adults, the normal ranges of vital signs are- temperature 35.8º-37.5 ºC, pulse 60-100 beats/ minute. Respiration rate 10-20 breaths/min and Blood pressure <120/80 mm Hg. The normal SpO₂ value is supposed to be between 95% to 100% and the normal blood glucose level is lesser than 7.8 mmol. A Glasgow Coma Scale (GCS) is concerned with the measurement of the best motor response, best verbal response and eye opening (Compter et al. 2014). For each of the categories, the lowest score is one (1). A GCS of 3 indicates no response towards pain, no verbal response and no eyes opening. A GCS of Eight (8) indicates severe injury; 9-12 indicates moderate injury and a GCS of 13-15 indicates minor injury (Sundararajan et al. 2014). In the given case scenario, the vital signs of the patient are – Temperature: 36.8º C, Pulse: 90, Blood pressure: 175/98, Respiratory Rate: 13, SpO₂: 92%, Blood glucose level: 6.6 mmol. The vital signs of the patient revealed that she has a normal body temperature; she has the symptoms of hypertension. Her Glasgow coma scale in the current situation is 11 (eyes open =3, best verbal= 2, best motor= 6), which reveals that she has issues with verbal communication. She has an elevated blood pressure with a fallen SpO₂ value.

Process the information

Distinguish – The blood pressure of Mrs. Amari has increased and the lowered SpO₂ values suggest a possible hypoxemia due to reduced level of oxygen in the blood especially in the arteries. There has been a problem in her circulatory system due to an interruption of the blood flow that might have increased the blood pressure and decreased the oxygen level in the blood.

Relate – Connecting the cues, it can be said that at the current situation, Mrs. Amari is having deterioration and considering her recent past of mini stroke or transient ischemic attack, she is having a relapse of the condition. Her blood flow to the brain has got interrupted that is causing the stroke like symptom of slurred speech and drooped mouth. Since she has got a history of hypercholesterolemia, hypertension, smoking and family history of heart disease, these factors have contributed collectively towards the development and relapse of the condition. Hypercholesterolemia can cause hypertension due to increased blood lipids that can also act as blockage of the blood flow in arteries.

Infer – Mrs. Amari is experiencing Transient Ischemic Attack (TIA) or mini stroke that mimics the symptoms of stroke. A TIA is not much different from a CVA however, the difference lies in the duration of occurrence and usually lasts for not more than 24 hours. Recurrence of TIA is alarming as it can cause the death of a huge number of neurons (Kernan et al. 2014). Therefore, it has to be taken as an opportunity and warning sign for preventing a stroke and an impending stroke respectively. It can be said that Mrs. Amari is on the verge of experiencing a stroke if not prevented.

References

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Compter, A., van der Worp, H.B., van Gijn, J., Kappelle, L.J., Koudstaal, P.J. and Algra, A., 2014. Is the long-term prognosis of transient ischemic attack or minor ischemic stroke affected by the occurrence of nonfocal symptoms?. Stroke, 45(5), pp.1318-1323.

Elliott, M. and Coventry, A., 2012. Critical care: the eight vital signs of patient monitoring. Br J Nurs, 21(10), pp.621-625.

Everson-Rose, S.A., Roetker, N.S., Lutsey, P.L., Kershaw, K.N., Longstreth, W.T., Sacco, R.L., Roux, A.V.D. and Alonso, A., 2014. Chronic stress, depressive symptoms, anger, hostility, and risk of stroke and transient ischemic attack in the multi-ethnic study of atherosclerosis. Stroke, 45(8), pp.2318-2323.

Galvin, R., Atanassova, P.A., Motterlini, N., Fahey, T. and Dimitrov, B.D., 2014. Long-term risk of stroke after transient ischaemic attack: a hospital-based validation of the ABCD 2 rule. BMC research notes, 7(1), p.1.

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Kernan, W.N., Ovbiagele, B., Black, H.R., Bravata, D.M., Chimowitz, M.I., Ezekowitz, M.D., Fang, M.C., Fisher, M., Furie, K.L., Heck, D.V. and Johnston, S.C.C., 2014. Guidelines for the prevention of stroke in patients with stroke and transient ischemic attack a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke, 45(7), pp.2160-2236.

Khan, H. and Shuaib, A., 2014.Transient Ischemic Attacks And Minor Strokes: How Newer Technologies Are Helping In Better Diagnosis Of High-Risk Patients And Response To Treatment. Khyber Medical University Journal, 6(4), pp.183-191.

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Nairn, R., DeSouza, R., Barnes, A.M., Rankine, J., Borell, B. and McCreanor, T., 2014. Nursing in media-saturated societies: implications for cultural safety in nursing practice in Aotearoa New Zealand. Journal of Research in Nursing, 19(6), pp.477-487.

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Sposato, L.A., Cipriano, L.E., Saposnik, G., Vargas, E.R., Riccio, P.M. and Hachinski, V., 2015. Diagnosis of atrial fibrillation after stroke and transient ischaemic attack: a systematic review and meta-analysis. The Lancet Neurology, 14(4), pp.377-387.

Sundararajan, V., Thrift, A.G., Phan, T.G., Choi, P.M., Clissold, B. and Srikanth, V.K., 2014. Trends over time in the risk of stroke after an incident transient ischemic attack. Stroke, 45(11), pp.3214-3218.