Stroke - Final Report

8/11/2019 Stroke - Final Report

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NGELES UNIVERSITY FOUND TION

School of Medicine

Cerebrovascul

ar ccident

Case Presentation

Submitted by:Group 4 | MD 3

Fajardo, Dona Pia

Francisco, AngelykaGamboa, Nina BiancaGangcuangco, JovelGarcia, BeejayGhimire, RupakGhimire, Kanchan

Gozum, Bryan

Hizon, AlphaIsais, Anne LyDriodoco, JuliDIZON, Reque


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P TIENT HISTORY

GENER L D T

RH is a 62 year old, female, married, from Sta. Cruz, Porac, Pampanga, who presented to the emergency

room with a chief complaint of r ight-sided weakness and numbness.

The source of the history is the patient and her two children, with a percent reliability of 95%.

D TE OF DMISSION:

September 19, 2014

HISTORY OF PRESENT ILLNESS

One week prior to admission, the patient woke up feverish and was warm to touch. She stated the

undocumented fever to be accompanied by a throbbing headache with a given a pain scale of 8/10. She

characterized the fever to be intermittent in onset with no association to the time of the day. Aside from the

headache, the patient also reported a right-sided tingling numbness on her face, as well as in the upper and

lower extremities with slight weakness or fatigue. Later that afternoon, the patient sought medical consult to

a private physician but did not speak of her numbness and weakness, and was just given paracetamol to be

taken as needed, and some vitamins that cant be recalled. She reported temporary relief of the fever andheadache with persistence of the numbness and weakness throughout the day. She had no cough or colds,

nausea or vomiting, or any history of recent illness.

For the past six days, the fever and headache persisted with same characteristics and without any

accompanying signs and symptoms. The patient also noted a progression of her right-sided numbness,

starting from a tingling sensation that daily progressed into a decrease in sensation. She also noted her

weakness to evolve from a sense of fatigability into a decrease in the range of motion and limitation of

function of the limbs which seem to affect the upper limbs more, affecting her activities of daily living.

A few hours before admission, the patient awoke around seven in the morning from a severe throbbing

headache with a pain scale of 10/10 and was afebrile. She stated to have taken 2 tablets of paracetamol to

relieve the pain but to no avail. She also noted a complete loss of sensation on the right side of her face andextremities, as well as severe weakness on the right upper limb with inability to raise her arm above her

shoulders or head nearing complete loss of function, and her lower limb being unable to support self in a

standing position or walking. With this, she was brought to Ospital Ning Angeles, and was admitted for

further evaluation.

The patient is not taking any maintenance medication and has no hypertension or diabetes.

P ST HISTORY

Birth and Developmental History

o No known congenital defects and chromosomal abnormalities

Childhood Illness

o (+) Measles, Mumps and Chicken pox (dates & age unrecalled)o (-) Rubella, Whooping cough, Rheumatic fever and Polio

Adult Illness

o Medical: (-) DM, HPN, Hepatitis, Asthma, HIV and other medical illnesses.

o Hospitalizations: No previous hospitalization

o Injuries/Accidents encountered: No previous injuries and accidents encountered.

o Surgical: No previous surgeries.

o Psychiatric History: Unremarkable.

Immunizations


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o Patient stated that she had the following vaccinations: (however, date & age unrecalled

o BCG, Tetanus, Pertussis, Diphtheria, Polio, Measles, Rubella, Mumps, Influenza, Hepatitis B,

Hemophilus, influenza type B

Screening Tests

o No Tuberculin test and Mammograms done.

o Pap smears once when patient was 47 years old which according to her had Normal

results.o Urinalysis & Blood chemistry (Cholesterol, FBS, Liver enzymes, Creatinine) Done 2x a year,

which according to her ALL had Normal results.

Allergies

o No known allergies to drugs, food & environmental allergens.

Medications

o No maintenance drugs taken.

OBSTETRIC/GYNECOLOGIC HISTORY

She was a G8P6 (6026), all delivered via NSD. With regards to the menstrual history, menarche was at 18

years old. Duration of menses lasts for 3 days, with moderate flow (2-3 pads/day), with regular monthly cycle

of 30 days. She was menopausal at age 47. Before menopause, she was not using any form of birth control.

She has only one sexual partner, male, and currently sexually inactive for more than 10 years (last intercourseat age 50). No history of any sexually transmitted infection.

F MILY HISTORY

The patients father died of liver cancer and her mother & grandparents died when she was still young. Her

siblings have no known illnesses. She has no known family history of asthma, hypertension, DM, hepatitis,

convulsions, TB, arthritis, stroke or hypercholesterolemia.

SOCI L & PERSON L HISTORY

Born and raised in Visayas, the patient moved to Angeles in 1947 in search for a better life. She was able to

attend school until grade 1 but she stopped because of financial constraints. She lives in her home with her 4

children. Their source of income is from selling their vegetable produce in the local market at Sunset Highway

Carmenville. The patient usually wakes up at 5am and does house chores before going to work at 9am. She

usually goes home from work at 6 pm. She does not take any rest days from work. The patient does not

exercise. She does not smoke, drink or use illicit drugs.

DIET RY & ENVIRONMENT L HISTORY

The patient consumes about 3-4 cups of coffee per day and her usual breakfast consists of coffee and bread

while her usual lunch and dinner consists of rice, pork or fish, or vegetables with softdrinks. Their drinking

water is from their faucet and it is not boiled. She lives with 3 members of the family in a concrete type of

house with pour-flush type of toilet, with adequate lighting and ventilation. Their house is located along the

road and is said to be quite polluted. Their garbage is not regularly collected, and instead burned

REVIEW OF SYSTEMS:

GENERAL

oWith weight loss

; no change in appetite;with weakness, fatigue

; with fever; no chills

SKIN

o No sores, lumps; no itching or rashes; no dryness; no color, hair or nail changes

HEENT

o Head: with headache, no dizziness or lightheadedness

o Eyes: with blurred visions, no pain, no redness or tearing, no discharge, no injuries

o Ears: no difficulty in hearing, no tinnitus, no discharge, no ear pain


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o Nose & Sinuses: no watery or purulent discharge, no epistaxis, no itching, no nasal

stuffiness

o Mouth & Throat: no change in the sense of taste, no bleeding gums, no sore throat, no

difficulty in speech, no hoarseness, no difficulty swallowing

NECK

o No swollen glands, no neck stiffness, no masses

BREASTSo No pain or discomfort; no lumps or masses

RESPIRATORY SYSTEM

o With dry cough, no dyspnea or shortness of breath, no wheezing, no hemoptysis

CARDIOVASCULAR SYSTEM

o With palpitations, no chest pain, no edema

GASTROINTESTINAL SYSTEM

o No trouble swallowing, no nausea, no vomiting, no hematemesis, no changes in bowel

habits, no abdominal pain, no melena or hematochezia, no rectal bleeding, no jaundice

URINARY

o No frequency of urination; no polyuria, nocturia, urgency; no burning or pain; no hematuria

EXTREMITIES

o With weakness; no gout or arthritis; no backaches NEUROLOGIC SYSTEM

o No fainting, no dizziness, with numbness, no seizures, no paralysis, no tremors, no

paresthesia, no alterations in consciousness, no difficulty in speech, no memory or sleep

disorder, with difficulty in walking

PSYCHIATRIC

o No significant behavioral changes, no hallucinations, no disorientation, no temper outburst

ENDOCRINE

o No thyroid enlargement, no heat or cold intolerance, no polyuria, polydipsia or polyphagia,

no excessive sweating

PHYSIC L EX M

GENERAL SURVEY

o The patient is cooperative and oriented to time, place and person. She is awake lying flat on

bed, weak-looking, appropriately dressed, without obvious deformities.

VITAL SIGNS:

o

o BP: 110/80 mmhg

o PR: 70 bpm

o RR: 23

o Temp: 36.8

MENTAL STATUS

o Conscious, coherent, cooperative, uses simple words, oriented to time, person, and place

SKIN

o No lesions, edema, or jaundice. skin is elastic, smooth, warm to touch

NAILS

o Nail plate is convex, pink nail beds, no clubbing.

HEENT

o Head: Skull is proportionate to body size, with a smooth contour, no scalp tenderness and

lesions, face is symmetrical with easy facial movements

o Eyes: Blink response is bilateral, with effective closure of eyelids, symmetrical eyeballs,

reactive to direct and consensual light and accommodation, sclera is white.

o Ears: Auricles are symmetrical and elastic, external canal has some cerumen, no discharge,

redness or swelling, normal hearing acuity


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o Nose & Sinuses: Septum at the midline, patent nares, no nasal discharges, no deformities,

no redness, no sinus tenderness

o Mouth & Throat: pink gums and buccal mucosa, uvula at the midline, symmetrical tongue

with easy movements, not inflamed and enlarged tonsils

NECK

o No visible lumps, mass, lesions or redness, no neck tenderness nonpalpable thyroid,

nonpalpable lymph nodes BREAST

o Not assessed

THORAX

o Lung expansion is normal and symmetrical anteriorly and posteriorly, no tenderness,

symmetrical tactile fremitus, regular breathing pattern, clear breath sounds, resonant upon

percussion. Heart sounds are normal. PMI at 5th ICS midclavicular line.

ABDOMEN

o Flat in shape, no visible blood vessels, pulsations or peristalsis, normoactive bowel sounds

(6/min); abdomen was tympanitic; liver span normal, spleen and kidneys were non palpable,

no palpable nodes or masses noted.

GENITOURINARY & RECTUM

o Not assessed MUSCULOSKELETAL

o No erythema, swelling, deformities, atrophy of muscles or tenderness

PERIPHERAL VASCULAR

o No edema; equal but weak pulses on all extremities

NEUROLOGICAL

o Mental status: conscious, coherent, oriented to person, place & time; obeys commands;

GCS 15

o Motor: No involuntary movements. Muscle strength of 5/5 on left limbs and 4/5 on right

limbs.

o Sensory: Feels light touch & pain on left limbs but has loss of sensation on her right limbs.

Graphesthesia intact.

CRANIAL NERVES:

o 1: No anosmia (vanilla correctly identified by smell in both nostrils)

o 2: Visual acuity not assessed; visual fields intact; fundoscopy optic disc is normal

o 2, 3: Pupils equal, round, reactive to light & accommodation

o 3, 4, 6: EOM intact

o 5: Sensory: intact sensations on left half of face, no sensation on right half of face; corneal

reflex intact

o Motor: masseter muscle strong bilaterally; no jaw deviation

o 7: Symmetrical facial features; can smile & raise eyebrows

o 8: Hearing intact in both ears

o 9, 10: Able to swallow; palate elevates symmetrically; uvula is midline

o 11: Able to turn head to left & right; able to shrug left shoulder but difficulty shrugging right

shoulder

o 12: Tongue is midline with no deviation or fasciculation noted


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C SE DISCUSSION

S LIENT FE TURES

Female

65

Intermittent fever

Headache

Right-sided numbness

Right-sided weakness

No cough or colds

No nausea or vomiting

Non-hypertensive

Non-diabetic

INITI L IMPRESSION

Mild Cerebrovascular Accident

DIFFERENTI L DI GNOSES

1. Ischemic Stroke

Ischemic stroke is characterized by the sudden loss of blood circulation to an area of the brain,

resulting in a corresponding loss of neurologic function. Acute ischemic stroke is caused bythrombotic or embolic occlusion of a cerebral artery.

RULE IN RULE OUT

Age: 62 years old

(+) fever

(+) weakness

(+) difficulty in walking

(+) visual disturbances

(+) persistent headache pain scale:

10/10

Neurologic symptoms:

- (+) unilateral weakness- (+) unilateral numbness

(-) hypertension

(-) history of cardiac problems

2. Transient Ischemic ttack

Transient ischemic attack is defined as a focal cerebral ischemic event that lasts less than 24 hours

and leaves no residual neurologic deficit.

The causes of TIA are similar to the causes of ischemic stroke, but because TIAs may herald stroke

they are an important risk factor that should be considered separately. TIAs may arise from emboli to

the brain or from in situ thrombosis of an intracranial vessel.

RULE IN RULE OUT

Age: 62 years old (+) headache

Neurologic symptoms:

- (+) unilateral weakness

- (+) unilateral numbness

neurologic symptoms:- (-) partial or complete unilateral loss of

vision

- (-) aphasia

stroke symptoms lasted more than 24

hours

(-) history of hypertension

(-) history of cardiac problems


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3. Intracranial Hemorrhage

Intracranial hemorrhage (ie, the pathological accumulation of blood within the cranial vault) may

occur within brain parenchyma or the surrounding meningeal spaces. Hemorrhage within the

meninges or the associated potential spaces, including epidural hematoma, subdural hematoma,

and subarachnoid hemorrhage. Intracerebral hemorrhage (ICH) and extension of parenchymal

bleeding into the ventricles (ie, intraventricular hemorrhage [IVH]).

Intracerebral hemorrhage accounts for 8-13% of all strokes and results from a wide spectrum of

disorders. Intracerebral hemorrhage is more likely to result in death or major disability than ischemic

stroke or subarachnoid hemorrhage. Intracerebral hemorrhage and accompanying edema may

disrupt or compress adjacent brain tissue, leading to neurological dysfunction. Substantial

displacement of brain parenchyma may cause elevation of intracranial pressure (ICP) and potentially

fatal herniation syndromes.

RULE IN RULE OUT

Age: 62 years old (>55)

(+) headache pain scale: 10/10

(+) unilateral weakness of extremities

(-) neck pain

(-) nuchal rigidity

(-) coma

(-) vomiting

(-) seizures

diastolic blood pressure of >110mmHg

4. Encephalitis

Encephalitis, an inflammation of the brain parenchyma, presents as diffuse and/or focal

neuropsychological dysfunction. Although it primarily involves the brain, the meninges are frequently

involved (meningoencephalitis).

Although bacterial, fungal, and autoimmune disorders can produce encephalitis, most cases are viral

in origin. The incidence of encephalitis is 1 case per 200,000 population in the United States, with

herpes simplex virus (HSV) being the most common cause. Considering the subacute and chronic

encephalopathies, the emergency department (ED) physician is most likely to encounter

toxoplasmosis in an immune-compromised host.

Herpes simplex encephalitis (HSE), which occurs sporadically in healthy and immune-compromised

adults is also encountered in neonates infected at birth during vaginal delivery and is potentially lethal

if not treated. Varicella-zoster virus encephalitis (VZVE) is life threatening in immune-compromised

patients. Swift identification and immediate treatment of HSE or VZVE can be lifesaving. From a

risk-benefit standpoint, most authorities recommend initiating ED treatment with acyclovir in any

patient whose central nervous system (CNS) presentation is suggestive of viral encephalitis,

especially in the presence of fever, encephalopathy, or focal findings, and in all neonates who appear

ill for whom a CNS infection is being considered.

RULE IN RULE OUT

Age: 62 years old (extremes of age)

(+) fever

(+) weakness



(-) neck pain

(-) photophobia

(-) lethargy

(-) seizures

(-) confusion

(-) amnestic state

(-) flaccid paralysis


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5. Hemiplegic Migraine

Hemiparesis occasionally occurs during the prodromal phase of migraine. Like the fortification

spectrum, it often resolves in 20 to 30 minutes, and contralateral head pain then begins. The

affected side may vary from attack to attack. A more profound form appears as hemiplegia, often

affecting the same side and persisting days or weeks after headache subsides.

This is the only migraine form linked to a specific gene. A clear autosomal dominant pattern of

attacks may appear within a family. The gene for familial hemiplegic migraine maps to chromosome

19 in one-half of the families.

RULE IN RULE OUT

(+) weakness

(+) difficulty in walking



(+) unilateral numbness

strokes come suddenly (rather than slowly

with one symptom and progress to other

symptoms)

(+) paralysis

(-) paresthesias

(-) history of migraine

occurrence: once (migraines may have

many attacks)

onset: late adulthood (hemiplegic migraine

symptoms often start in childhood and

disappear in adulthood)

6. Brain Tumor

A primary brain tumor is one that originates in the brain, and not all primary brain tumors are

cancerous; benign tumors are not aggressive and normally do not spread to surrounding tissues,

although they can be serious and even life threatening.

One risk factor is age. People over the age of 65 are diagnosed with brain cancer at a rate four times

higher than younger people.

The symptoms of brain cancer are numerous and not specific to brain tumors, meaning they can be

caused by many other illnesses as well. The only way to know for sure what is causing the

symptoms is to undergo diagnostic testing.

RULE IN RULE OUT

Age: 62 years old

(+) persistent headache

(+) weakness

(+) difficulty walking

neurologic symptoms:

- (+) unilateral weakness

- (+) unilateral numbness

(-) seizure attacks

(-) nausea/vomiting acute and progressive onset of symptoms

(rather than a more gradual onset)

DI GNOSTIC PROCEDURES

Imaging studies

Emergent brain imaging is essential for confirming the diagnosis of ischemic stroke.

1. CT scanning


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Imaging with CT scanning has multiple logistic advantages for patients with acute stroke. Image

acquisition is faster with CT scanning than with MRI, allowing for assessment with an

examination that includes noncontrast CT scanning, CT angiography (CTA), and CT perfusion

scanning in a short amount of time. Expedient acquisition is of the utmost importance in acute

stroke imaging because of the narrow window of time available for definitive ischemic stroke

treatment with pharmacologic agents and mechanical devices.

CT scanning can also be performed in patients who are unable to tolerate an MR examination or

who have contraindications to MRI, including implantable pacemakers, some aneurysm clips, or

other ferromagnetic materials in their bodies. Additionally, CT scanning is more easily accessible

for patients who require special equipment for monitoring and life support.

2. MRI

Conventional (spin echo) MRI may take hours to produce discernible findings in acute ischemic

stroke. Diffusion-weighted imaging (DWI) is highly sensitive to early cellular edema, which

correlates well with the presence of cerebral ischemia. For this reason, many centers include

DWI in their standard brain MRI protocol. DWI MRI can detect ischemia much earlier than

standard CT scanning or spin echo MRI can and provides useful data in patients with stroke or

transient ischemic attack (TIA)..

3. Transcranial Doppler ultrasonography

Useful for evaluating more proximal vascular anatomyincluding the middle cerebral artery

(MCA), intracranial carotid artery, and vertebrobasilar arterythrough the infratemporal fossa.

Echocardiography is obtained in all patients with acute ischemic stroke in whom cardiogenic

embolism is suspected.

4. Chest radiography

Has potential utility for patients with acute stroke. However, obtaining a chest radiograph should

not delay the administration of rt-PA, as radiographs have not been shown to alter the clinical

course or decision-making in most cases.

5. Conventional angiography

It is the gold standard in evaluating for cerebrovascular disease as well as for disease involving

the aortic arch and great vessels in the neck. Conventional angiography can be performed to

clarify equivocal findings or to confirm and treat disease seen on MRA, CTA, transcranial

Doppler, or ultrasonography of the neck.

Blood Studies

1. CBC

A CBC serves as a baseline study and may reveal a cause for the stroke (eg, polycythemia,

thrombocytosis, thrombocytopenia, leukemia) or provide evidence of concurrent illness (eg,

anemia).

2. Basic Chemistry

The basic chemistry panel serves as a baseline study and may reveal a stroke mimic (eg,

hypoglycemia, hyponatremia) or provide evidence of concurrent illness (eg, diabetes, renal

insufficiency).

3. Coagulation Studies

Coagulation studies may reveal a coagulopathy and are useful when fibrinolytics or


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Major Steps in the Cascade of Cerebral Ischemia

anticoagulants are to be used. In patients who are not taking anticoagulants or antithrombotics

and in whom there is no suspicion for coagulation abnormality, administration of rt-PA should

not be delayed while awaiting laboratory results.

4. Cardiac Biomarkers

Cardiac biomarkers are important because of the association of cerebral vascular disease and

coronary artery disease. Additionally, several studies have indicated a link between elevations of

cardiac enzyme levels and poor outcome in ischemic stroke.

5. Toxicology Screening

Toxicology screening may be useful in selected patients in order to assist in identifying

intoxicated patients with symptoms/behavior mimicking stroke syndromes. In patients with

suspected hypoxemia, arterial blood gas studies define the severity of hypoxemia and may

detect acid-base disturbances. However, arterial punctures should be avoided unless absolutely

necessary in patients being considered for fibrinolytic therapy.

EPIDEMIOLOGY

Stroke is the leading cause of disability and the fourth leading cause of death in the United States. Each year,

approximately 795,000 people in the United States experience new (610,000 people) or recurrent (185,000

people) stroke. Epidemiologic studies indicate that approximately 87% of strokes in the United States areischemic, 10% are secondary to intracerebral hemorrhage, and another 3% may be secondary to

subarachnoid hemorrhage.

According to the World Health Organization (WHO), 15 million people suffer stroke worldwide each year. Of

these, 5 million die, and another 5 million are left permanently disabled.

Based on disability-adjusted life-years, stroke is the second leading cause of death and among the top five

diseases with the greatest burden in the Philippines. Although two community-based studies have been

conducted to determine the prevalence of stroke, the incidence has not been nationally recorded to date.

The prevalence ranged from 19% to 659%

P THOPHYSIOLOGY

Acute occlusion of an intracranial

vessel causes reduction in blood

flow to the brain region it supplies.

The magnitude of flow reduction is a

function of collateral blood flow and

this depends on individual vascular

anatomy, the site of occlusion, and

likely systemic blood pressure. A

decrease in cerebral blood flow to

zero causes death of brain tissue

within 4-10 minutes; values


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Focal cerebral infarction occurs via two distinct pathways: (1) a necrotic pathway in which cellular

cytoskeletal breakdown is rapid, due principally to energy failure of the cell and (2) an apoptotic pathway in

which cells become programmed to die. Ischemia produces necrosis by starving neurons of glucose and

oxygen, which in turn results in failure of mitochondria to produce ATP. Without ATP, membrane ion pumps

stop functioning and neurons depolarize, allowing intracellular calcium to rise. Cellular depolarization also

causes glutamate release from synaptic terminals; excess extracellular glutamate release from synaptic

terminals; excess extracellular glutamate produces neurotoxicity by activating postsynaptic glutamatereceptors that increase neuronal calcium influx. Free radicals are produces by membrane lipid degradation

and mitochondrial dysfunction. Free radicals cause catalytic destruction of membranes and likely damage

other vital functions of cells. Lesser degrees of ischemia, as are seen within the ischemic penumbra, favour

apoptotic cellular death causing cells to die days to weeks later. Fever dramatically worsens brain injury

during ischemia, as does hyperglycemia, so it is reasonable to suppress fever and prevent hyperglycemia as

much as possible

Three major mechanisms that underlie ischemic stroke

1. Occlusion of an intracranial vessel by an embolus that arises from a distal site

2. In situ thrombosis of an intracranial vessel,

3. Hypoperfusion caused by flow-limiting stenosis of a major extracranial or intracranial vessel


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M N GEMENT

Step 1: Prehospital ssessment

A. Activate Emergency Medical Service system in all potential CVA patients

B. Transport to hospital with Stroke Team if possible (otherwise nearest facility)

Step 2: Immediate General ssessment (110 mmHg)


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1. Failure to control Blood Pressure 92%

E. Consider Thiamine in Alcoholics and malnourishment

Step 5: Observe for and treat complications

A. Seizures

1. Treat with Diazepam and Phenytoin

B. Cerebral edema (peaks on day 3-5, duration 10 days)

1. Severe, large volume cerebral edema (malignant edema)

2. Responsible for one third of CVA cases that deteriorate

3. Repetitive strain injury and Intubate

4. Mannitol or hypertonic saline

5. Neurosurgery Consultation for decompression

6. Corticosteroids are not indicated

C. Delirium

1. Avoid medications that cause Altered Level of Consciousness (e.g. sedatives,

Anticholinergics)

2. Preserve normal sleep-wake cycle by avoiding disturbing night-time sleep

3. Maintain orientation by maximizing sensory input (adequate lighting, eliminate background

noise)

D. Pressure Sores (Decubitus Ulcer)

1. Early mobilization and frequent turning

2. Frequent skin examination

3. Alternating pressure mattresses

4. Maintain adequate nutrition

E. Malnutrition

1. Assess albumin and Cholesterol as markers of malnutrition

F. Fever

1. Associated with worse outcome in Ischemic Stroke

2. Thoroughly investigate for fever cause


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A sudden headache, especially when accompanied by nausea, vomiting, or dizziness

REFERENCES

Harrisons Principles of Internal Medicine, 18th Edition http://www.drugs.com/cg/cerebrovascular-accident.html

http://nurseslabs.com/cerebrovascular-accident-nursing-management/ http://www.fpnotebook.com/Neuro/CV/CvMngmnt.htm

http://emedicine.medscape.com

http://www.ncbi.nlm.nih.gov/pubmed

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Stroke - Final Report