Neurologic Emergencies in Older Adults: A Case Study and Differential Diagnosis, Exams of Nursing

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Neurologic Emergencies in older Adult

Walden University NRNP 6540F Advanced Practice Care of Older Adults

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Neurologic Emergencies in

Older Adult

Walden University

NRNP 6540F Advanced Practice Care of

Older Adults Name…

November 8, 2023

Neurologic Emergencies in older Adult

Walden University NRNP 6540F Advanced Practice Care of Older Adults

Neurologic Emergencies in Older Adult Stroke is the 4th^ leading cause of disability in the United States. Early recognition and treatment are crucial to the reversibility and extent of the symptoms. The goal of this paper is to present a subjective, objective, assessment, and plan (SOAP) for an older patient with presenting neurologic symptoms. The paper also aims to present the differential diagnoses for this case and their associated treatments and teachings. The paper will reflect on the learnings encountered while reviewing the case study. SOAP Note Subjective Patient Information : Mr. Mario, 66-year-old, Male, Hispanic Chief Complaint : Mr. M was brought in to the emergency department by the advance squad team with reports of acute aphasia, right facial droop, and right sided weakness. History of Present Illness : Mr. M is a 66-year-old Hispanic male who was brought in by fire rescue for acute aphasia, right facial droop, and right sided weakness. The sudden onset of symptoms occurred at work at the post office where one of his co-workers notified 911. The ambulance noted neurologic symptoms that alerted the emergency department for a possible

Neurologic Emergencies in older Adult

Walden University NRNP 6540F Advanced Practice Care of Older Adults

stroke alert. The patient is a known hypertensive but non-compliant with his hypertensive

Neurologic Emergencies in older Adult

Walden University NRNP 6540F Advanced Practice Care of Older Adults

medications. Mr. M was recently diagnosed with diabetes with prescription for oral hypoglycemic agent. He is a heavy smoker and morbidly obese. Current Medications : Antihypertensive medication Oral hypoglycemic agent Allergies : Unknown Past Medical History : Hypertension Immunization status unknown Unknown last visit to the primary care physician Social and Substance History : Works part time in a post office Smoker, smokes about a pack and a half per day Sedentary lifestyle that contributed to his excessive weight Family History :

Neurologic Emergencies in older Adult

Walden University NRNP 6540F Advanced Practice Care of Older Adults

Both parents died of myocardial infarction in their 60’s

Surgical History : No surgical history reported Review of Systems :

• General: No fever or chills. Reports right sided weakness. No weight loss or weight gain.
• Head: No headache. No trauma reported.
• Eyes: No eye pain, photophobia, diplopia, spots or floaters, discharge, itching, cataracts or glaucoma.
• Ears, Nose, Mouth/Throat (ENT): No changes in or loss of hearing. No ear pain, tinnitus, ear drainage. No changes in or loss of sense of smell, nose bleed, polyps, rhinorrhea, itching, sneezing, and sinus problems. Denies ulcerations or lesions in tongue, bleeding gums, gingivitis, dentures or dental appliances.
• Respiratory: No shortness of breath, cough, coughing up blood, mucus, wheezing, or night sweats.
• Cardiovascular: No chest pain, orthopnea, murmurs, irregular heartbeats, palpitations, peripheral edema, claudication, leg pain, or varicose veins. Wife reports uncontrolled

Neurologic Emergencies in older Adult

Walden University NRNP 6540F Advanced Practice Care of Older Adults

hypertension and non-compliance with hypertensive medication. Both parents died of myocardial infarction at age 60.

• Gastrointestinal: No abdominal pain, nausea, vomiting, heartburn, regurgitation, jaundice, diarrhea, constipation, hematochezia, hematemesis, or hemorrhoids.
• Genitourinary: No dysuria, frequency, urgency, nocturia, incontinence, and history of sexually transmitted infections.
• Musculoskeletal: No arthralgias, arthritis, gout, joint swelling, neck pain, or back pain. Denies any fall or any pain.
• Neurologic: Reports right sided weakness. Rescue reports acute aphasia and facial droop that started immediately prior to arrival.
• Psychiatric: No depression, suicidal thoughts or ideation, delusions, or visual/auditory hallucinations. Denies emotional disturbances, sleep disturbances, substance abuse disorders,
• Integumentary: No changes to skin, hair, and nails. No rashes, pruritus, dryness, or skin lesions.
• Endocrine: Recently diagnosed with diabetes and is taking an oral hypoglycemic medication. No changes in hair or skin texture.
• Hematologic: No easy bruising, bleeding tendency, anemia, blood transfusions, thromboembolic disorders and lymphadenopathy.

Neurologic Emergencies in older Adult

Walden University NRNP 6540F Advanced Practice Care of Older Adults

• Allergic/Immunologic: No rhinitis, asthma, skin sensitivity, food or latex allergies, or sensitivity.

Objective Physical exam: General: Alert, awake, aphasic, weakness noted to right side. Appears anxious. Vital Signs: Vital signs need to be obtained. Height 5’5”, 255 lbs. BMI 42.4 (obese) Blood pressure is increased in majority of patients with acute stroke and is associated with poor outcomes, hence, initial blood pressure is important and prompt management is crucial. HEENT: Head: Normocephalic and atraumatic. No tenderness or bruits of temporal arteries. Eyes: Pupils equal, round, and reactive to light and accommodation. Conjunctiva pink and moist mucous membranes. No AV nicking, hemorrhage or exudates on fundoscopic exam. No abnormal discharge noted. No periorbital swelling noted. Ears: Patent external auditory canal. No swelling noted. No abnormal ear discharges noted. Tympanic membranes pearly gray, no erythema or effusion noted.

Neurologic Emergencies in older Adult

Walden University NRNP 6540F Advanced Practice Care of Older Adults

Nose: Nares patent bilaterally. Nasal mucosa pink without rhinorrhea. No nasal deviation, flaring, or nasal polyps noted. Throat: No erythema or visible exudates noted. Mucus membrane moist and pink. Teeth intact. Neck: Supple neck with limited range of motion. Thyroid not enlarged. No carotid bruits or jugular vein distention. No masses palpated. No tracheal deviation. Respiratory: Symmetrical chest wall and diaphragmatic excursions. Respirations equal and clear throughout the lung fields. No increased effort in breathing noted. Cardiovascular: Heart regular rate and rhythm. S1 and S2 noted. No murmurs, gallops, or rubs. PMI at 5th^ intercostal space, midclavicular line. Distal pulses are symmetrical bilaterally 3+. No peripheral edema noted. Gastrointestinal: Abdomen soft and nontender, and non-distended. Bowel sounds present and active in all quadrants. No guarding or rebound tenderness noted. Genitourinary: No costovertebral angle tenderness noted. Musculoskeletal: Limited range of motion in extremities to the right side. No joint effusions, clubbing, cyanosis, or edema. Neurologic: Alert, awake, aphasic. Right facial droop noted. NIH Stroke Scale 18. Right arm and right leg drifts and hits bed. Moderate loss of sensation to right side with pin prick. Integumentary: No rash or lesions noted. Skin color appropriate for age. Skin warm and dry.

Neurologic Emergencies in older Adult

Walden University NRNP 6540F Advanced Practice Care of Older Adults

Good skin turgor.

Neurologic Emergencies in older Adult

Walden University NRNP 6540F Advanced Practice Care of Older Adults

Lymphatics: No lymphadenopathy noted in the neck or femoral area. Diagnostic test:

1. Brain CT Scan (Plain) – Negative for hemorrhage or early signs of ischemia

Assessment Differential diagnoses:

1. Ischemic Stroke Stroke symptoms typically present as neurologic deficits with sudden onset. The symptoms depend on the part of the brain that is affected. Usual symptoms of stroke in the left hemisphere include aphasia, right hemiparesis and right hemianopia (Masuka et al., 2015). Mario presented with acute aphasia, right facial droop, and right sided weakness, which are pertinent positives for a left sided ischemic stroke. His symptoms occurred acutely while at work in the post office which indicative of an acute stroke. Kennedy-Malone et al. (2019) stated that hypertension, diabetes, and cigarette smoking are contributing factors for a stroke. Mario has all three factors, in addition to obesity and sedentary lifestyle, making him high risk in the development of a stroke event. 2. Toxic Metabolic Disorder (Hypoglycemia) The significance of diabetes as a risk factor for the occurrence of stroke is well established in literature. Frequent exposure to hypoglycemia is seen in both types one and two

Neurologic Emergencies in older Adult

Walden University NRNP 6540F Advanced Practice Care of Older Adults

diabetic patients. Pre-clinical studies show that hypoglycemia increases the risk of stroke in all

Neurologic Emergencies in older Adult

Walden University NRNP 6540F Advanced Practice Care of Older Adults

patients with diabetes (Smith et al., 2018). Mario, in the case study, is a newly diagnosed diabetic; and if found with low blood sugar when his symptoms presented, he has a pertinent positive indication for the diagnosis. It was reported in the case study that the blood sugar was checked by the advance squad team and reported to the team of the receiving hospital. Hypoglycemia mimics the symptoms of stroke. In a recent study, among 80 consecutive hypoglycemic patients (less than 50 mg/dL), 11 patients had focal neurologic signs, and the most frequent symptom was unilateral weakness accompanied by mild or moderate decrease in levels of consciousness (Ohshita et al., 2015). The initial diffusion weighted imaging in patients with hypoglycemia with focal neurologic symptoms (HFNS) show a hyperintense lesion that is hard to distinguish from acute cerebral infarction (Ohshita et al., 2015). Mario shows focal neurologic symptoms. If his blood sugar was significantly low (below 50 gm/dL), and his imaging shows a disproportionately small lesion in contrast to neurological signs, hypoglycemia should be ruled in.

3. Conversion Disorder (Functional Neurological Disorder) Conversion disorder is a common stroke mimic of either transient ischemic attack (TIA) or ischemic stroke. Functional neurological disorders are previously called psychogenic or conversion disorders. Seventy percent of functional stroke mimics present with limb weakness and sensory disturbances (Popkirov et al., 2020). The said symptoms are pertinent positives for Mario. He came in with aphasia and right sided weakness which are reasons for considering this diagnosis. A good examination technique to differentiate functional from pathological weakness is crucial for early decision making and prevent misdiagnosis. A recent study reported that conversion disorders in stroke patients are more likely to be female, younger, and have no history

Neurologic Emergencies in older Adult

Walden University NRNP 6540F Advanced Practice Care of Older Adults

of diabetes, hypertension, or atrial fibrillation as compared to patients with ischemic stroke or

Neurologic Emergencies in older Adult

Walden University NRNP 6540F Advanced Practice Care of Older Adults

TIA patients (Wen et al., 2019). The characteristics mentioned were all pertinent negatives for the patient in the case study. Mario is an older male with a history of hypertension and diabetes. For these reasons, this diagnosis can be ruled out. Patient has no known psychiatric or psychologic history to associate this diagnosis with and no stressor has been stated to contribute to this diagnosis for Mario.

Plan Laboratory/Diagnostic Tests:

1. Computed Tomography (CT) Scan of the Brain- Patient within the time window for intravenous thrombolytic are recommended by guidelines to have a non-contrast CT scan or MRI to exclude cerebral hemorrhage or evaluate ischemic changes. Non-contrast CT scan is the first line imaging tool in suspected stroke and recommended as an initial mode of imaging to determine decisions for IV alteplase. Ischemic changes in the anterior aspect of the brain can be identified in the scan using the Alberta Stroke Program Early CT Score, a simple 10-point CT score dividing the mid-cerebral artery territory into 10 regions (Lin & Liebeskind, 2016). By identifying that there is no hemorrhage in the CT scan, providers will rule in that an ischemic stroke is positive if symptoms are still persistent; hence, it identifies if the patient is a candidate for thrombolysis. However, this test has a specificity of 56% to 100% and poor sensitivity of 20 to 75% for detecting ischemic changes in the early stage (six to eight hour window), especially for posterior

Neurologic Emergencies in older Adult

Walden University NRNP 6540F Advanced Practice Care of Older Adults

strokes (Lin & Liebeskind, 2016). A diffusion weighted imaging (DWI) is a better

Neurologic Emergencies in older Adult

Walden University NRNP 6540F Advanced Practice Care of Older Adults

imaging modality for early ischemic stroke. The onset of Mario’s symptoms was not specified, but the case reported that a co-worker identified the symptoms at work and called 911 immediately. If onset of symptoms were less than six hours, the ischemic stroke is in its early stage; hence, the CT result performed did not identify it but confirmed that it was negative for a hemorrhage. If a posterior stroke is suspected, then a DWI would be a better option for the provider.

2. Magnetic Resonance Imaging (MRI) – Patients with symptoms presenting as acute vestibular syndrome or suspected posterior infarction is recommended to undergo acute DWI MRI (Yew & Cheng, 2015). The said imaging modality has a sensitivity of 91% to 100% and specificity of 86% to 100% (Lin & Liebeskind, 2016). However, MRI may miss posterior strokes in the first 48 hours; hence, a repeat MRI in three to seven days should follow a negative initial MRI result to exclude a false negative result (Yew & Cheng, 2015). MRI shows greater sensitivity for small volume ischemia or when there is no time pressure to offer treatment; therefore, it is used as a follow-up imaging. 3. CT Angiography – The imaging will identify occluded intracranial vessel and evaluate extracranial carotid, extracranial vertebral, aortic arch and proximal great vessels in managing major ischemic stroke, if not immediately, then over the next several days (Musaka et al., 2015). 4. Carotid Duplex- This is a type of ultrasound to check if the cause is due to carotid artery stenosis, which is narrowing of the major blood vessels that supplies blood to the brain. 5. PT/INR and aPTT – Coagulation studies is important during a stroke. The American Heart and Stroke Association released the 2018 guidelines for the early management of

Neurologic Emergencies in older Adult

Walden University NRNP 6540F Advanced Practice Care of Older Adults

patients with acute ischemic stroke. The guideline stated that patients with clearly no

Neurologic Emergencies in older Adult

Walden University NRNP 6540F Advanced Practice Care of Older Adults

current use of warfarin, non-vitamin K antagonist, or heparin may have intravenous thrombolysis started prior to the said lab results, but needs to be stopped when INR is over 1.7 (Lokeskrawee et al., 2019).

6. EKG – Electrocardiogram will be ordered to detect any underlying heart disorder. According to Chaturvedi (2017), atrial fibrillation is the leading cause of cardioembolic stroke, and is paroxysmal in a significant proportion of patients. In addition, EKG can detect other relevant cardiac issues including myocardial ischemia and ventricular arrhythmias. 7. NIH Stroke Scale – The scoring scale is developed to help clinicians to objectively rate the severity of the ischemic stroke. Higher scores indicate a severe score and usually correlates with the size of the blockage in the artery in the CT scan and MRI **Treatment

1. Keep patient nothing by mouth –** Stroke patients are at risk for aspiration due to central or local weakness or incoordination of the muscles in the pharynx or impaired gag reflex **2. Oxygen Nasal cannula for oxygen saturation below 94%.
2. Administer Alteplase (onset is less than 4.5 hours) –** Intravenous administration of recombinant tissue plasminogen activator (alteplase) has shown to lower functional disability, with an absolute risk reduction of 7%-13%nas compared to placebo; hence, has become the major specific treatment recommended in the management of an acute ischemic stroke (Musuka et al., 2015). Efficacy wanes quickly and associated risks like bleeding increases with time elapsed from symptom onset; therefore, early diagnosis and

Neurologic Emergencies in older Adult

Walden University NRNP 6540F Advanced Practice Care of Older Adults

treatment is required. Patients with disabling acute ischemic changes are candidates for

Neurologic Emergencies in older Adult

Walden University NRNP 6540F Advanced Practice Care of Older Adults

alteplase and Mario is a candidate if his symptoms of aphasia, facial droop and right sided weakness are still present within 4.5 hours of symptom onset with a negative bleed in the CT scan.

4. Mechanical Thrombectomy - If there is large vessel occlusion, within 24 hours of symptom onset, an endovascular thrombectomy may be indicated for Mario. The procedure involves the removal of a thrombus under imaging guidance. The procedure is enabling; however, this may only be available in comprehensive stroke center or tertiary hospitals with a stroke team. A stroke team will manage and intervene timely and provide follow up hyperacute care in a stroke unit. Follow up Follow up will depend on the type and extent of the stroke and rehabilitation assessment should be done before discharge. Rehabilitation should be initiated during the acute phase with a goal of restoring the highest level of functioning possible (Kennedy-Malone et al., 2019). Referral Referral is dependent on the type and severity of the neurological deficits and the comorbidities. With Mr. Mario, it is best to refer to different specialists such as neurology, vascular surgery, cardiology for consultation. Education

1. Result of the CT Scan

Neurologic Emergencies in older Adult

Walden University NRNP 6540F Advanced Practice Care of Older Adults

Educating Mario’s wife, Lucinda, about the importance of the CT Scan in diagnosing stroke would be important. A non-contrast CT scan of the brain is the current standard in diagnosing stroke because it is fast and widely available. A brain CT scan rules in a diagnosis of hemorrhagic stroke (whether intracerebral or subarachnoid hemorrhage) with more than 95% accuracy rate (Musaka et al., 2015). It also rules in a diagnosis of major stroke in over 60% of cases in which ischemic changes are obvious. With Mario’s CT scan as negative for hemorrhage, the providers in the case can order for alteplase if he is within the window of 4.5 hours from the onset of symptoms.

2. Signs and Symptoms Educating Mario’s wife on the signs of an impending stroke is important because stroke can recur. Early identification is the key to help the patient and the family to seek for treatment faster. Signs and symptoms to watch for would include: unilateral weakness and numbness in the face, hand, arm or leg; difficulty with speech or comprehension; problems with vision such as blurriness, double vision or decreased vision; loss of balance or coordination; and severe headache, often described as the worst headache of their life (Kennedy-Malone et al., 2019).
3. Risk Factors A widely used stroke tool to predict stroke risks is the Framingham Stroke Risk Profile (FSRP). The FSRP uses risk factors such as age, systolic BP, antihypertensive treatment, diabetes, cigarette smoking, left ventricular hypertrophy by EKG, and the presence of heart diseases (like coronary heart disease, peripheral vascular disease, and congestive heart failure) as stroke predictors and it can be used to estimate a 10-year stroke risk (Boehme et al., 2017).

Neurologic Emergencies in older Adult

Walden University NRNP 6540F Advanced Practice Care of Older Adults

Teaching the family on the causes of stroke is crucial, so they can control the individual risk factors and prevent future events. In Mario’s case, four risk factors for having a stroke include his history of diabetes, cigarette smoking, history of heart diseases (hypertension), and his body weight or obesity. The four risk factors are emphasized because they are modifiable risk factors. Mario is a newly diagnosed diabetic. Diabetes is an independent risk factor for stroke. Literature shows that risk doubles in stroke for diabetic patients and that 20% of deaths in diabetics is due to stroke (Boehme et al., 2017). According to Boehme et al. (2017), cigarette smoking is a major risk factor for stroke, doubling the risk with a dose response relationship between the number of pack years and risk for stroke. Mario was reported to smoke to a pack and a half daily. Meanwhile, hypertension is the most modifiable risk factor for stroke. Hypertension has a significant, direct and continuous relationship with stroke risk (Boehme et al., 2017). Mario has been reported to be non-compliant with his medications for his blood pressure. Uncontrolled hypertension puts him at a very high risk for a stroke. Lastly, on obesity, it was noted that Mario has a BMI of 42.1, which is considered as obesity. A recent large meta- analysis showed that 76% of the effect of the BMI on stroke risk was mediated by elevated blood pressure, cholesterol, and glucose levels (Boehme et al., 2017).

4. Home exercise programs to maintain optimal functional levels will be encouraged. Tailored exercise programs with balance training components will reduce falls, enhance cardiorespiratory fitness and improve cognition and memory (Kennedy-Malone et al., 2019). Periodic follow up with the primary provider to monitor recovery, complications, manage risk factors and secondary prevention.

Neurologic Emergencies in older Adult

Walden University NRNP 6540F Advanced Practice Care of Older Adults

Reflection

Neurologic Emergencies in older Adult

Walden University NRNP 6540F Advanced Practice Care of Older Adults

From the case, it was learned that neuroimaging provides crucial information about the brain and the vessels to enhance rational decisions to start reperfusion therapy. CT scan is the gold standard in identifying an ischemic stroke, but it does not confirm early ischemic stroke. It is also interesting to note that different imaging modalities are available to confirm the specific cause of the ischemic stroke. Imaging protocols are also dependent on available resources, local preference, and preference of the clinician. It is vital that a nurse practitioner has adequate expertise and uses proper clinical context, along with the imaging results to accelerate decision making. Summary Stroke is one of the leading causes of death and disability in the country. Advances in the diagnosis and treatment are now available to help decrease the stroke burden in our society, especially to the older population. Stroke is characterized by the acute onset of neurologic symptoms like acute aphasia, facial droop, and unilateral weakness, which were the presenting symptoms of the patient in the case study. As the first provider to see the patient with acute stroke, their decision can have a profound impact in the outcome of stroke. Follow up care, referral and adequate teaching are significant for the patient’s recovery to ensure that a stroke patient like Mario will have his highest functional abilities restored and maintained.

Neurologic Emergencies in older Adult

Walden University NRNP 6540F Advanced Practice Care of Older Adults

References Boehme, A. K., Esenwa, C., & Elkind, M. S. (2017). Stroke risk factors, genetics, and prevention. Circulation Research , 120 (3), 472–

495. https://doi.org/10.1161/CIRCRESAHA.116.308398 Chaturvedi, S. (2017). Importance of the prehospital ECG in acute stroke patients. New England Journal of Medicine. https://www.jwatch.org/na44121/2017/05/24/importance- prehospital-ecg-acute-stroke-patients Kennedy-Malone, L., Martin-Plank, L., & Duffy, E. (2019). Central and peripheral nervous system disorders. In Advanced practice nursing in the care of older adults (2nd ed., p. 328–360). F. A. Davis. Lin, M. P., & Liebeskind, D. S. (2016). Imaging of ischemic stroke. Continuum , 22 (5), 1399–
496. https://doi.org/10.1212/CON.0000000000000376 Lokeskrawee, T., Muengtaweepongsa, S., Inbunleng, P., Phinyo, P., & Patumanond, J. (2019). Accuracy of laboratory tests collected at referring hospitals versus tertiary care hospitals for acute stroke patients. Plos One. https://doi.org/10.1371/journal.pone.0214874 Musuka, T. D., Wilton, S. B., Traboulsi, M., & Hill, M. D. (2015). Diagnosis and management of acute ischemic stroke: Speed is critical. Canadian Medical Association Journal , 187 (12), 887–893. https://doi.org/10.1503/cmaj.140355