CASE STUDY:

A 32-year-old white female presents to Urgent Care with complaints of blurry vision and “fuzzy thinking” which has been present for the last several weeks. She works as an executive for an insurance company and puts her symptoms down to the stress of preparing the quarterly report.

Today, she noticed that her symptoms were worse and were accompanied by some fine tremors in her hands. She has been having difficulty concentrating and has difficulty voiding. She remembers her eyes were bothering her a few months ago and she went to the optometrist who recommended reading glasses with a small prism to correct double vision. She admits to some weaknesses as well.

No other complaints of fevers, chills, upper respiratory tract infections, or urinary tract infections. Past medical and social history is non-contributory. The physical exam is significant for the 4^th cranial nerve palsy. The fundoscopic exam reveals edema of the right optic nerve causing optic neuritis. Positive nystagmus on positional maneuvers.

There are left visual field deficits. There was short-term memory loss with the listing of familiar objects. The APRN tells the patient that she will be referred to a neurologist due to the high index of suspicion for multiple sclerosis (MS).

Question:

What is multiple sclerosis and how did it cause the above patient’s symptoms? 

Case study:

A 67-year-old male presents to the clinic along with his family with a chief complaint of having problems with his short-term memory. His family had dismissed these problems and attributed them to the aging process.

Over time they have noticed changes in his behavior, along with increased confusion and difficulty completing basic tasks. He got lost driving home from the bowling alley and had to be brought home by the police department. He is worried that he may have Alzheimer’s Disease (AD).

Past medical and social history is positive for a minor cerebral vascular accident when he was 50 years old but without any residual motor or sensory defects. No history of alcohol or tobacco use. Current medication is clopidogrel 75 mg po qd.  Neurological testing confirms the diagnosis of AD.

Question:

What is Alzheimer’s Disease and how does amyloid-beta factor into the development and progression of the disease

Case study:

A 22-year-old male was an unrestrained front seat passenger of a car traveling at 50 miles per hour. The driver swerved to avoid hitting a deer that darted in front of the car and hit a tree. EMS on the scene noted a stellate fracture of the windshield on the passenger side.

The patient was non-responsive at the scene when the paramedics arrived, and his pupils were unequal with the left pupil larger and sluggish to react to light. He was placed in a hard-cervical collar per the protocol and log rolled onto a long backboard.

He was breathing spontaneously at the scene, but pulse oximetry in the EMS unit revealed a SaO₂ of 78% on room air. He was intubated at the scene for airway protection and transported to a Level 1 trauma center. Glasgow Coma Scale=3

After a full trauma workup, the patient was diagnosed with an isolated traumatic brain injury with acute subdural hematoma secondary to the coup-contrecoup mechanism of injury.

He was emergently taken to the operating room for craniotomy after which he was taken to the Intensive Care Unit (ICU) for close monitoring. He had an intracranial bolt for measurements of his intracranial pressure (ICP).

Question:

Explain the differences between primary and secondary traumatic brain injuries (TBIs)? 

The APRN is called by the ICU staff because the patient’s ICP has risen to 22 mmHg. The APRN recognizes the urgent need to lower the ICP. The APRN institutes measures to decrease the ICP and increase the cerebral perfusion pressure (CPP). What are the factors that determine CPP?

Case study:

An 83-year-old man presents with a history of atrial fibrillation (AF), hypertension, and diabetes. His daughter, who accompanied the patient, states that yesterday the patient had a period when he could not speak or understand words and that approximately 4 weeks prior he staggered against a wall and was unable to stand unaided because of weakness in his legs. She states that both instances lasted approximately a half-hour. She was unable to persuade her father to go to the emergency room either time.

Today he suffered another episode of right-sided weakness, dysarthria, and difficulty with speech. Past medical history: Hypertension for 15 years, well-controlled; diabetes for the past 10 years, and  Medications: Diltiazem CD 300 mg daily; lisinopril 40 mg daily; metformin 500 mg twice daily; aspirin 81 mg daily and atorvastatin 20 mg po qhs.

Social history: reported former smoker with 40 pack-year histories. Alcohol -drinks one beer a day. Denies any other substance abuse. Review of systems: Denies dyspnea, dizziness, or syncope; complains that he cannot move or feel his right arm or leg. Difficulty with speech.

Physical exam: Vitals: height = 70 inches; weight = 185 pounds; body mass index = 26.5; BP = 134/82 mm Hg; heart rate = 88 bpm at rest, irregularly irregular pattern.

HEENT: remarkable for expressive aphasia, eyes with contralateral homonymous hemianopsia.

No loss of sensation but unable to voluntarily move right arm or leg.

The patient was diagnosed with a right middle cerebral artery vascular accident (CVA) secondary to atrial fibrillation (AF)

Question:

How does atrial fibrillation contribute to the development of a CVA? 

Case Study :

A 34-year-old Caucasian female presents to the clinic with a chief complaint of widespread pain in her joints and muscles. She states that her skin seems sensitive, and sometimes it hurts to be touched.

The Caucasian female has had extreme fatigue for the past 4 months. She admits to being depressed and is unable to sleep well. She has had to drop out of her gardening club due to pain. She says that bright lights and loud noises really bother her.

Past medical history noncontributory. Her social history was significant for her divorce from her husband 14 months ago. She is the mother of 2 small children and works as an administrative assistant at the local insurance company.

Physical exam remarkable for tender points over her posterior supraspinatus muscles, occiput, trapezius, gluteal area, and sacroiliac joints bilaterally. BASED ON HER PHYSICAL EXAM, the APRN tells the patient that she most likely has fibromyalgia.

Question :

What are the underlying causes of fibromyalgia? 

The APRN tells the patient that the tender points are no longer used to diagnose FM. She suggests that the patient takes the Widespread Pain Index (WPI) and the Symptom Severity Inventory (SSI).

The patient asks the APRN what these tests are for. What is the APRN’s best answer?