A 35-year-old woman presents to neurology clinic with new onset of diplopia. She had presented several months earlier for left leg weakness. At that time, she had a computed tomography (CT) of the head, which was negative, and her symptoms resolved within a week. The client has a history of seasonal allergies, migraines, and back pain after a motor vehicle accident 6 years ago. The client reports fatigue and states that she has had a fever and rhinorrhea for the past 4 days. The client is alert and oriented, and her neurologic exam is negative aside from her diplopia.
Vital signs:
- Temperature: 98.6°F (37°C)
- Heart rate: 108 beats per minute
- Respiratory rate: 20 breaths per minute
- Blood pressure: 110/68 mmHg
- Pulse oximetry reading: 97%
| Laboratory Value | Result | Reference Range |
| Red blood cells (RBC) | 4.5 million/uL | Females 4.2-5.4 million/uLMales 4.7-6.1 million/uL |
| Hemoglobin (Hgb) | 13.2 g/dL | Females: 12-16 million/uLMales 14.7-16.1 million/uL |
| Hematocrit (Hct) | 43% | Females 37%-47%Males 42%-52% |
| White blood cell count (WBC) | 7000/mm3 | 5000-10,000/mm3 |
| Platelets | 190,000/uL | 150,000-450,000/uL |
| Glucose | 105 | Below 200 mg/dL |
| Blood urea nitrogen | 18 | 7-20 mg/dL |
| Creatinine | 0.8 mm/hr | Females 0.93 mg/dLMales 1.13 |
- Regular diet
- Vital signs every 4 hours
- Neurologic check every 4 hours
- MRI
done
That’s right!
Rationale:
Potential Condition: Multiple sclerosis (MS) is a progressive autoimmune disorder that occurs more frequently in women and initially presents in the 3rd to 5th decades of life. The disease is characterized by demyelination and degeneration of the nerves of the brain and spinal cord. A client with a stroke will present with sudden onset facial drooping, slurred speech, and hemiplegia/hemiparesis. Seizures are characterized by abnormal electrical discharges of cerebral neurons, leading to uncontrolled movements that can be associated with electrolyte abnormalities or other causes. Meningitis is an infection of the brain causing headache, photophobia, and nuchal rigidity and would be associated with an increased white blood cell count and abnormal lumbar puncture results. Relevant Cues: Clients with MS often present with focal weakness or diplopia. Symptoms are acute in onset and resolve on their own within days to weeks to months. Clients also report fatigue, gait instability, spasticity, paresthesias, nystagmus, genitourinary and gastrointestinal dysfunction, and depression. The client tachycardia is unrelated and could be because of fear or another cause. Her back pain is related to her previous motor vehicle accident. Her rhinorrhea is unrelated to MS and may be as a result of her seasonal allergies or infection. Parameters to Monitor: Because of the neurologic basis of MS, the monitoring of this client would involve visual and reflex exams. Frequent neurologic exams and imaging including magnetic resonance imaging (MRI). Lesions may not be present until several years after the onset of the symptoms, and diagnosis is difficult. Because there is no infectious process taking place, temperature monitoring is not necessary. Urinary output would monitor renal function and hydration status and is also unrelated. Telemetry is not necessary because the heart is not involved in MS.
Neurologic – Patient 2
An 85-year-old nursing home resident presents to the emergency department (ED) with a report of a fever with mental status changes and not eating the past 3 days. Per nursing home records, client is usually conversational and alert to person and place. On arrival to the ED, the client has his eyes closed and is groaning but does open eyes to verbal stimuli. Client has a history of dementia and osteoarthritis.
Vital signs:
- Temperature: 102.6°F (39.2°C)
- Heart rate: 88 beats per minute
Respiratory rate: 18 breaths per minute - Blood pressure: 118/78 mmHg,
- Pulse oximetry reading: 96%.
Admission Day 1, 0800: Client is lethargic but responding to verbal stimuli.
Admission Day 2, 0800: Client returns to baseline, ambulating, and asking for “real food.”
Admission Day 3, 0800: Client was witnessed to have an episode today that consisted of muscle rigidity with urinary incontinence that lasted for 3 minutes, followed by somnolence.
| Laboratory Value | Day 108:00 | Day 208:00 | Day308:00 | Reference Range |
| Red blood cells (RBC) | 5.5 million/uL | 5.3 million/uL | 5.4 million/uL | Females 4.2-5.4 million/uLMales 4.7-6.1 million/uL |
| Hemoglobin (Hgb) | 16.2 g/dL | 15.2 g/dL | 14.0 g/dL | Females: 12-16 million/uLMales 14.7-16.1 million/uL |
| Hematocrit (Hct) | 45% | 43% | 43% | Females 37%-47%Males 42%-52% |
| White blood cell count (WBC) | 12,000/mm3 | 12,000/mm3 | 10,000/mm3 | 5000-10,000/mm3 |
| Platelets | 170,000/uL | 165,000/uL | 160,000/uL | 150,000-450,000/uL |
| Glucose | 115 | 97 | 106 | Below 200 mg/dL |
| Sodium | 135 mEq/L | 128 mEq/L | 118 mEq/L | 136-145 mEq/L |
| Chloride | 106 mEq/L | 102 mEq/L | 92 mEq/L | 98-106 mEq/L |
| Potassium | 6.1 mEq/L | 4.3 mEq/L | 3.3 mEq/L | 3.5-5.0 mEq/L |
| Bicarbonate | 23 mEq/L | 22 mEq/L | 24 mEq/L | 23-30 mEq/L |
| Blood urea nitrogen | 27 | 24 | 19 | 7-20 mg/dL |
| Creatinine | 1.8 mm/hr | 1.2 mm/hr | 0.7 mm/hr | Females 0.93 mg/dLMales 1.13 |
- NPO
- IV antibiotics
- Vital signs Q4
- Inputs and outputs
- Urinalysis
- Dextrose 5% in 0.9% NaCl IV at 100 mL/hr
Chest x-ray showed left lower lobe pneumonia with atelectasis.
done
That’s right!
Rationale:
The client was admitted with altered mental status that may have been due to infection (pneumonia on x-ray). There was also evidence of dehydration and acute kidney injury requiring fluid replacement. Because the fluid was replaced, the labs indicate hyponatremia developed, which can lead to seizures. Options for 1: Uremia is a condition of high blood levels of urea. On day 3, this client’s blood urea nitrogen (BUN) was within normal limits. Infection can cause seizures, but this client was improving as evidenced by a white blood cell count, which returned to normal. The fluids that were administered have improved the dehydration by day 3, as evidenced by BUN and creatinine return to normal. The client was normoglycemic on all 3 days according to the provided results. Options for 2: The signs and symptoms of stroke include acute onset slurred speech, paralysis, and visual disturbances and would not resolve in a few minutes. The blood glucose levels do not indicate diabetes. This client does have pneumonia, but this is unlikely to be the cause of seizures in this case. Although the client initially presented with some acute renal failure, the BUN and creatinine on day 3 show resolution.
Neurologic – Patient 3
A 68-year-old right-handed client presents at 1900 to the emergency department (ED) with severe headache, slurred speech, and right-sided weakness that first began in the morning but has since progressed. The client has a history of diabetes, hypertension, congestive heart failure, chronic obstructive pulmonary disease, obstructive sleep apnea, and morbid obesity. The client is alert and oriented to person, place, and time but is unable to move the right arm or leg with diminished reflexes on the right side. On further questioning, the client also reports shortness of breath and polyuria.
Vital signs:
- Temperature: 99.3°F (37.4°C)
- Heart rate: 88 beats per minute
- Respiratory rate: 20 breaths per minute
- Blood pressure: 184/108 mmHg
- Pulse oximetry reading: 94%
| Laboratory Value | Results | Reference Range |
| Red blood cells (RBC) | 4.8 million/uL | Females 4.2-5.4 million/uLMales 4.7-6.1 million/uL |
| Hemoglobin (Hgb) | 15.2 g/dL | Females: 12-16 million/uLMales 14.7-16.1 million/uL |
| Hematocrit (Hct) | 44% | Females 37%-47%Males 42%-52% |
| White blood cell count (WBC) | 8000/mm3 | 5000-10,000/mm3 |
| Platelets | 460,000/uL | 150,000-450,000/uL |
| Glucose | 285 | Below 200 mg/dL |
| Sodium | 142 mEq/L | 136-145 mEq/L |
| Chloride | 104 mEq/L | 98-106 mEq/L |
| Potassium | 4.6 mEq/L | 3.5-5.0 mEq/L |
| Bicarbonate | 24 mEq/L | 23-30 mEq/L |
| Blood urea nitrogen | 20 mg/dL | 7-20 mg/dL |
| Creatinine | 1.1 mg/dL | Females 0.93 mg/dLMales 1.13 mg/dL |
- Vital signs Q4
- Neurologic checks Q4
- Capillary blood glucose monitoring
- NPO
- ASA 81 mg po daily
- Atorvastatin 40 mg po QHS
- Seizure precautions
- Dextrose 5% in 0.45% NaCl at 83 mL/hr
- Low dose sliding scale insulin aspart
- Lisinopril 20 mg po daily
- Swallow evaluation
- Speech therapy
- Physical therapy
- Occupational therap
Computed tomography (CT) head negative for any acute infarct.
done
That’s right!
Rationale:
Potential Condition: Stroke or cerebrovascular accident (CVA) is caused by an interruption in blood supply by either a rupture or blockage of a blood vessel supplying the brain. This client has acute onset of severe headache, slurred speech, and right-sided weakness, which is a typical presentation of a client with CVA. A seizure is caused by irregular electrical activity of the brain and commonly manifests as tonic-clonic movements, followed by a post-ictal state. Meningitis is an infection of the brain that is associated with fever, headache, and nuchal rigidity. Guillain-Barré syndrome is an ascending paralysis that is often preceded by an infection. Relevant Cues: Clients with stroke have an acute onset of facial paralysis, slurred speech, hemiplegia, and/or severe headache. Other cues include dysfunction of bowel and bladder elimination, intellectual function, spatial-perceptual alterations, personality, affect, sensations, and swallowing. The client’s polyuria may be due to diabetes or infection. Hyperglycemia may be due uncontrolled diabetes. Shortness of breath could be due to this client’s congestive heart failure or chronic obstructive pulmonary disease. Parameters to Monitor: Clients presenting with stoke will have frequent neurologic checks, which will include reflexes. Blood pressure control is also especially important in the management of the client with a cerebrovascular accident (management may include initial permissive hypertension), and thus monitoring of blood pressure is important. Telemetry is not required in a client with stroke and would be needed for cardiac disease. Temperature would be monitored in clients who have infections such as meningitis. Urinary output would be monitored in renal disorders and infections of the urinary tract.