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Neurological and Musculoskeletal Disorders (Vignette Questions and Answers)
Vignette Student Response Questions and Answers
Vignette 23: Cerebral Artery Vascular Accident (CVA)
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 hyperlipidemia. 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 history. 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?
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Neurological and Musculoskeletal Disorders (Vignette Questions and Answers)
Vignette Student Response Questions and Answers
Vignette 22: Traumatic Brain Injuries (TBIs)
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 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 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 work up, the patient was diagnosed with an isolated traumatic brain injury with acute subdural hematoma secondary to 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 1 of 2:
Explain the differences between primary and secondary traumatic brain injuries (TBIs)?
<Type your response here>
Question 2 of 2:
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?
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Neurological and Musculoskeletal Disorders (Vignette Questions and Answers)
Vignette Student Response Questions and Answers
Vignette 21: Spinal Cord Injury (SCI)
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. The patient was ejected from the vehicle. He was awake and alert at the scene when the paramedics arrived, and his pupils were equal and reactive to light. He was placed in a hard-cervical collar per 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 88% on room air. He was placed on 100% oxygen via non-rebreather mask and was taken to a Level I trauma center with the following vital signs:
Vital signs: BP 90/50, Pulse 48 and regular, Respirations 24 and shallow with some use of accessory muscles, temp 95.2 F rectally. He was awake and answering questions appropriately but says he cannot feel his arms or legs. Glasgow Coma Scale 14. His skin was warm and dry with minor abrasions noted on his arms. According to family members, past medical history noncontributory and social history reveals only occasional alcohol use and no tobacco or vaping history. Full work up in the ED revealed a fracture-dislocation of C4 with assumed complete tetraplegia (formerly called quadriplegia). No other injuries noted He was given several liters of IV fluid, but his blood pressure remained low.
Question 1 of 2:
Explain the differences between primary and secondary spinal cord injury (SCI)?
<Type your response here>
Question 2 of 2:
What is spinal shock and how it is different from neurogenic shock?
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