Case Study: 70-year-old male with poorly controlled blood pressure and hyperlipidemia who presents after an episode of lightheadness that resulted in a fall. He complained of left-hand numbness and visual disturbances that resolved after 15 min. Physical examination showed irregular heart rhythm, tachycardia and hypertension.
More information about patient: onset unilateral weakness, smokers ½ pack per day. Alcohol: single shot of whiskey most nights. He has post-stroke depression.
Main diagnoses: Stroke
Differential Diagnoses with rationales
- 1- Transient ischemic attack (TIA)
- 2- Seizure:
The diagnostic Plan:
Identify lab, radiology, or other test need it for the main diagnosis of Stroke
Specific Treatment Plan, Education and Follow up: include medication name, dosage and frequency; patient/ family; appropriate follow up plan and consults when appropriate based on appropriate clinical guidelines.
Instructions:
- APA format with intext citations.
- Write 2 pages, not including references.
- References: 3 high-level scholarly references within the last 5 years in APA format.
- Plagiarism free.
- Turnitin receipt.
Introduction
The case study presents a 70-year-old male with poorly controlled blood pressure and hyperlipidemia who presents after an episode of lightheadness that resulted in a fall. The patient complained of left-hand numbness and visual disturbances that resolved after 15 minutes. Physical examination showed an irregular heart rhythm, tachycardia, and hypertension. The patient has a history of smoking and drinking, post-stroke depression, and a family history of hypertension. This essay presents a discussion of the differential diagnoses, diagnostic plan, specific treatment plan, education, and follow-up for the patient’s main diagnosis of stroke.
Differential Diagnoses
The patient’s symptoms of lightheadedness, left-hand numbness, and visual disturbances can be attributed to various differential diagnoses. The two most likely differential diagnoses are transient ischemic attack (TIA) and seizure. TIA is a temporary blockage of blood flow to the brain that causes stroke-like symptoms but resolves within 24 hours. Seizure, on the other hand, is a sudden surge of electrical activity in the brain that can cause changes in behavior, movement, or sensation. Both TIA and seizure can cause lightheadedness, numbness, and visual disturbances.
The patient’s irregular heart rhythm, tachycardia, and hypertension increase the risk of stroke, making TIA the most likely differential diagnosis. The patient’s family history of hypertension, post-stroke depression, and smoking also increase the risk of stroke. The patient’s smoking habit also increases the risk of atherosclerosis, which can lead to stroke.
Diagnostic Plan
The diagnostic plan for the patient’s main diagnosis of stroke involves identifying lab, radiology, or other tests needed. A non-contrast head CT scan should be performed to identify any signs of acute bleeding or brain damage. MRI and MRA can be used to detect ischemic changes and the location of the stroke. EKG can be used to identify any arrhythmias or heart abnormalities that increase the risk of stroke. Blood tests can be performed to determine the patient’s cholesterol and blood sugar levels.
Specific Treatment Plan, Education, and Follow-up
The specific treatment plan for the patient’s stroke involves immediate hospitalization and monitoring of vital signs. The patient should be given aspirin to reduce the risk of stroke recurrence. Intravenous tissue plasminogen activator (tPA) can be given to dissolve the blood clot causing the stroke if the patient arrives at the hospital within 3-4.5 hours of the onset of symptoms. If the patient is not a candidate for tPA, he should be given anticoagulants, such as heparin, to prevent further clotting. Blood pressure should be monitored and controlled to prevent further damage to the brain.
The patient and his family should be educated on the importance of managing hypertension, hyperlipidemia, and smoking cessation to prevent future strokes. The patient should be advised to take his medications as prescribed, follow a healthy diet, and engage in regular physical activity. The patient should also be monitored for any signs of post-stroke depression and referred to a mental health professional if necessary.
The appropriate follow-up plan for the patient involves regular visits to his primary care physician or a neurologist to monitor his blood pressure, cholesterol levels, and medication regimen. The patient should be advised to return to the hospital immediately if he experiences any recurrent stroke symptoms.
Conclusion
In conclusion, the case study presents a 70-year-old male with poorly controlled blood pressure and hyperlipidemia who presents after an episode of lightheadedness that resulted in a fall. The patient complained of left-hand numbness and visual disturbances that resolved after 15 minutes. The patient’s main diagnosis is stroke, and the most likely differential