Case Study Traumatic Brain Injury |

Case Study Traumatic Brain Injury

Case Study: Traumatic Brain Injury
Name of Student
Name of Institution
Traumatic Brain Injury
A fifty-six years old male by the name Scott, a resident of Massachusetts, United States was
presented to the emergency room accompanied by his wife and a friend at around 6.00 PM in the
evening. The man was brought by an emergency ambulance after the wife had contacted them
following a phone call from a friend about her husband’s condition that had left him
unconscious. Mr Scott had visited one of the cafés in the neighborhood after returning home
from school. He is a high school teacher and it was his routine and to the rest of his friends to
meet at the café for drinks. The friend explained that Scott had complained of fatigue right from
when they had met at the restaurant. Unlike other days, he did not take any drink for the time
they were together. His friend also recounted that he complained of a severe headache. His wife
added that her husband had suffered Ischemic stroke-embolic, post motorcycle accident about
two months earlier. The accident left him with serious head injuries and had been on medication
including pain medication, since then.
Physical examination
On assessment, the patient was noted to be suffering from aphasia because he could not
communicate his feeling. He looked confused and dull. He had difficulties in holding a glass by
himself. The doctor noted that the patient had dysphagia while trying to drink water. These
indications were associated with pain. Scott struggled to make body movements particularly the
arms and the head. The assessment noted elevated blood pressure. It was far higher than normal
blood pressure. Additionally, the examination identified a faster heart rate than 100 beats per
Weight: 158 pounds
Height: 5’6”
Body Mass Index (BMI): 26.1
Key signs
Respirations: 15
Blood pressure: 168/112*
Oxygen saturation: 95% on room air
Temperature: 99.8 Fahrenheit
Pulse rate: 124*
Diagnostic and lab tests
Clot in aorta
Carotid Ultrasound
35% blockage in the right carotid artery and 40% blockage in a left carotid artery.
CT Brain
There was no evidence of bleed noted
MRI Brain
Infarct found left middle coronary artery (MCA)
Lipid Panel
Triglycerides: 183* Greater than 40-170 mg/dL
LDL: 138* <130 mg/dL
HDL: 25* 30-75 mg/dL
Cholesterol (total): 212* <200 mg/dL
0.00 Normal Value 0.00-0.01
Complete Blood Count
RBC: 6.4* 4.2-5.6 M/L
WBC: 7.4 3.8-11 K/mm3
Platelets: 475,000 150,0000-450,000 μl
Hct: 58%* 39-54%
Hgb: 17 14-18 gm/dL
MCHC: 33 31-37%
PT/INR 6 seconds, 0.9* PT:10-14 seconds, INR: <2.0
Amylase: 85 50-150 U/dL
Lipase: 120 10-140 U/L
MCV: 90 78-98 fL
MCH: 34 27-35 pg
Comprehensive Metabolic Panel
ALT: 27 0-30 IU/L
AST: 14 7-21 IU/L
Albumin: 4.2 3.5-5.0 g/dL
Blood Urea Nitrogen: 21 8-25 n mg/dL
Calcium: 9.4 8.0-11.0 mEq/L
Creatinine: 1.3 0.6-1.5 mg/dL
Chloride: 105 96-112 mEq/L
Carbon Dioxide:32 21-34 mmol/L
Potassium: 4.5 3.5-5.0 mEq/L
Glucose: 215* 65-99 mg/dL
HbA1C: 8.1* Less than 7%
Sodium: 135 135-145 mEq/L
Magnesium:2.5 1.5-2.5 mg/dL
Phosphorous:3.5 2.2-4.8 mg/Dl
Bold indicates abnormal
Bold* indicates alert values
Precipitating Factors
Mr. Scott was diagnosed with Stroke less than two months ago. He was put on medication which
he was expected to observe timely prescription to the letter. The wife indicated that Scott had not
been adhering to the doctor’s prescriptions all the time. She said that the patient failed to take the
pills many times that he took them. She added that at times the husband was stubborn and
reluctant to take the pills even when reminded to do so. The wife had carried with her, her
husband’s pill bottle. It indicated that Scott had not been taking the medicines as was required of
him. Considering the fact that the patient had a history of stroke, his failure to comply with the
doctor’s prescription was a risk factor which perhaps would have contributed to him suffering
from Recurrent Stroke. Additionally, Scott used to drink alcohol persistently despite the doctor’s
advice against doing so. He used to drink too much alcohol once he got out of his job place.
Drinking of liquor particularly in large volumes is a risk factor for recurrent stroke as well as ill
health in humans. Too much alcohol stops the liver from producing substances that are
responsible for blood clotting. This increases the risk of having stroke caused by bleeding in the
brain. Scott is used to a sedentary lifestyle even when he is not at work. He is used to watching
television during his leisure. Scott is hardly used for physical activities. His doctor had
recommended him to do weight training and other physical activities regularly to increase
physical fitness and help improve his condition. However, he has not been actively involved in
these activities. His sedentary lifestyle is a significant risk for stroke. The lab report, carotid
ultrasound indicates the formation of plaque that prevents blood flow in his carotid arteries. This
is a risk factor for stroke. Scott has a history of diabetes. The wife said that he had been
diagnosed with diabetes on many occasions with the doctor insisting on the need for adhering to
diabetic diet restriction. However, it is noted that the patient has not been following the
guidelines. Considering the patient’s comprehensive metabolic panel report, the hemoglobin AIC
is 8.1 which indicates that diabetes is not appropriately controlled. Diabetes is a common risk
factor for stroke, particularly if not managed effectively. Additionally, the patient has a history of
high blood pressure. The lab tests show a very high blood pressure result of 168/112 which is
much higher than the normal high blood pressure. This is a significant risk factor for stroke as
well. Scott has not been observing the requirements of a healthy dietary lifestyle. This is
determined by the kind of food that an individual eats. This is a crucial determinant for a healthy
life. The assessment reveals high cholesterol levels indicated by elevated triglycerides of up to
183 which is higher than the normal levels. Additionally, he is overweight. This is shown by the
Body Mass Index (BMI) of 26.1. This is obesity comparing with a healthy BMI of 18.5-24.9.
The high cholesterol levels and obesity are risk factors for stroke as well. The lab report indicates
that the patient has elevated platelets count. This puts him once more at high risk of stroke. The
age of the patient is itself a risk factor for stroke. Aged individuals are more likely to suffer
stroke than young ones. People aged fifty years and above have a higher risk of stroke than those
with less. Since the patient is fifty-six years old, he is at a higher risk of recurrent Stroke. There
is a high probability of the same condition recurring given that he has not been observing the
doctor’s prescription as well as increased exposure to many risk factors of stroke.
History and Physical Assessment
Severe headache
• Dysphagia
Elevated heart rate
Elevated blood pressure
Right lower and upper extremity weakness.
Right-sided visual neglect
Right facial droop
Right-sided sensory impairment
Diagnostic Findings
Aortic clot
Elevated PT/INR
Atrial fibrillation
Elevated triglycerides
Embolus blocking left MCA
Secondary polycythemia
Elevated cholesterol
Elevated platelets
Carotid artery blockage
Left MCA infarct
Elevated blood glucose.
Cellular Analysis
Headache- In a stroke, the patient experiences severe headache because certain regions
of the brain gets damaged. The pain becomes even more severe when bleeding takes place on the
brain. This happens when the blood clot causes rapture to the blood vessel leading to internal
injury. It can also be felt if the spinal cord and other related sensory pathway which take part in
body coordination are damaged as well. Alternatively, patients on medication particularly those
for blood pressure may experience severe headache resulting from the effects of these drugs.
Confusion- Confusion can result from memory lose which is attributed to the the damage
of temporal lobe due to stroke. Temporal lobe is responsible for memory storage and retrieval of
the same. Additionally, confusion can be as a result of damage in the front lobe. This is
responsible knowledge and intellectual behavior. These events make a patient unable to
comprehend information or communicate constructively. Scott gradually developed memory lose
right from when he experienced the first stroke. There is high possibility that he had developed
retrograde amnesia. This leads to the loss of memory and inability to make and store new
Dysphagia- Swallowing which occur during eating is facilitated by a network of region
within the cerebral cortex including the cingulate, prefrontal gyrus, insula, and somatosensory.
These regions should be activated when a person has to take nutritional swallow. In case of
reflective swallow, only sensorimotor area is activated. This mechanism is triggered by sudden
stimuli such as the drop of food into pharynx. When a patient gets stroke, one or more of these
regions is essentially damaged therefore disrupting the coordination in the network resulting to
the failure of the process. Therefore, swallowing is impaired. Scott’s dysphagia condition was as
result of failure in coordination of different regions within the cerebral cortex.
Aphasia is manifested by the inability of a patient to communicate, read or write after a
stroke. The frontal lobe of the left hemisphere and particularly the Broca’s area is responsible for
controlling the functions that relates to language and speech. If this part of the brain is damaged
by the stroke, and blood tends to flow in the same section, then, the patient is left with the effects
of aphasia. This makes the patient unable to speak, write or comprehend a speech. Essentially,
there are different types of aphasia expressive, receptive, amnesia and global. The most common
aphasia is global. This combines the three other types including expressive, receptive and
amnesia. This involves a scenario where a patient cannot speak, write, read and the same time
and cannot comprehend or keep the memory. Scott’s condition suggested that there his Broca’s
area of his left hemisphere was damaged. This contributed to his state of inability to speak of and
or communicate his conditions as well.
Elevated heart rate- The normal heartbeat occurs when the sinoatrial (SA) node triggers
an electrical impulse which is passed through the left and right auricles. This causes contraction
of the atrium muscles. The contraction causes blood to move to the ventricles. This results the
rhythmic movement of the heart. When an electrical impulse in triggered from a different region
of the atrium other than the sinoatrial node or at the pulmonary vein, the result is an abnormal
contractions of the atriaum. In fact, disorganized signals are distributed to the leading to fast and
irregular contraction and relaxation of atria. This causes increased heart rate. The medical
assessment noted that Scott had an elevated heart rate. This resulted from disorganized signal
distribution to the atria due to imbalances detected within the mechanisms responsible for
regulation of body temperature. As such, fast and irregular contractions occurred within the atria
as the system tries to offset the imbalance. This resulted in increased heart rate.
Elevated blood pressure- This is associated with various factors including lack of
exercise, poor diet, and excessive consumption of alcohol among others. Acute high blood
pressure can cause stroke. This is because it makes the blood vessels thicker but much weaker to
withstand blood pressure. Scott, having a history of high blood pressure was advised to do to
carry out regular physical exercise but never complied to the advice. Again, he was advised on
the need for diet regulation which he failed to adhere as well. These events increase Scott’s risks
of suffering from recurrent ischemic stroke. Additionally, Scott used to take excessive alcohol
even when he was under medication. These were also risk factors that perhaps contributed to the
stroke. On assessment, the doctor found that Scott’s left MCA was blocked by an embolus to the
area of brain. This blockage made the heart to work harder in pumping the blood to the brain
than in normal circumstances. This led to increased blood pressure.
Right lower and upper extremity weakness- Scott’s left MCA was damaged which
resulted in the weakening of the muscles of the right side of his body. The motor signal passed
from the cortex, passes through the internal capsule and then travels to the brain stem which
forms the pyramids of medulla. The pyramid fibers cause the movement to travel to the opposite
of the body other than where the signal is sent. This causes muscles weaken to the side of the
body that gets affected. The conditions affects various body organs including both fore limb and
hind limb as well as the face.
Right-sided visual neglect- This occurs when a patient is not able to see out of the right
side of each eye. In human, vision is enhanced by the occipital lobe of the brain. The occipital
lobe on the left interprets visual signals from the right visual space while the right occipital lobe
interprets the visual signals from the right visual space. Scott’s right side of the brain failed to
receive sufficient blood flow as a result of the clot. He was not able to see properly on the left
side of his visual field. Therefore, he was not able to see out of his right side of each eye.
Right facial droop- The facial droop occurs when the nerves that control the facial
muscles and their movement are damaged in the brain. When Scott had stroke, nerves that
control muscles in his right face got damaged, therefore, causing drooping on his right face.
Right-sided sensory impairment- This sensory impairment occurs when parietal lobe gets
damaged by stroke. The parietal lobe is the one responsible for interpretation of sensory signals
including touch, pain and pressure. The impairment occurred on the right side of Scott’s body
because the infarct had occurred on the left side of his brain.
Diagnostic Findings
Aortic clot- When an electrical impulse occurs from a different region of the atrium other
than the sinoatrial node, the result is an abnormal contractions of the atriaum. The disorganized
signals are distributed to the atria leading to irregular contraction and relaxation of atria. The
blood is not sent to the ventricles as it should be, rather it gathers in the atria of the heart. The
pooling blood forms a blot clot to a common sport and particularly in the aorta.
Elevated PT/INR- This standard ratio measures the amount of time that it takes for an
individual’s blood to clot. Scott’s PT/INR was low indicating that his blood was thicker than it
ought to have been. Therefore it clotted quickly. The prothrombin is the clotting factor in blood.
A measure of prothrombin time is referred to as PT. On the other hand, INR stands for
International Normalized Ratio. Therefore, the ratio between the two indicates the rate at which
the blood clots across the individuals.
Atrial fibrillation- The normal heartbeat occurs when the sinoatrial (SA) node triggers an
electrical impulse which is passed through the left and right auricles. This causes contraction of
the atrium muscles. The contraction causes blood to move to the ventricles. On the other hand,
atrial fibrillation occurs when an electrical impulse is triggered from a different region of the
atrium other than the sinoatrial node or at the pulmonary vein. It cause disorganized distribution
of signals hence causing fast and irregular contraction and relaxation of atria.
Elevated triglycerides- Increased levels of triglyceride in blood plasma results from
consumption of unhealthy food. Scott had a history of eating unhealthy food. This is according to
his wife during physical examination at the hospital. It is justified by the fact that the lab report
that indicated a very high triglyceride level of 183. Triglycerides are the chemical form of fat
that are found in food and the blood plasma. It comes from fats and carbohydrates in the food
eaten by individuals. If calories are not immediately used by the body, the calories are stored in
fat cells in the form of triglyceride.
Embolus blocking left MCA- Scott’s clot formed in the aorta as a result of atria
fibrillation. A clot shifted from the aorta and moved to the left MCA causing the blockage of
oxygenated blood to the brain. Essentially, an embolus is a blood clot that breaks from its
original site and moves to a different site.
Secondary polycythemia- The blood forming organs in the body automatically produces
large numbers of red blood cells whenever the tissues become hypoxic. The level of hematocrit
indicates the amount of blood which is made up of red blood cells. Considering that Scott’s red
blood cells were elevated, his hematocrit was elevated too. Hemoglobin is found inside the red
blood cells and plays a major role in the transportation of oxygen from the lungs to the rest of the
body cells. The glucose enters the red blood cells and links up with a molecule of hemoglobin.
The more glucose is present in the blood, the more hemoglobin gets glycated. Measuring the
percentage of AIC in the blood, gives an indication of the average blood glucose control.
According to the assessment, Scott’s blood sugar level was high. The wife indicated that Scott
did not comply with the diabetes diet restrictions. It is no wonder that his blood sugar is high.
Elevated cholesterol- Given that Scott’s triglyceride and LDL were elevated, his total
cholesterol was elevated too. The addition of LDL, HDL and the 20% of the triglyceride level.
Cholesterol is formed in the liver and then transported to the body by low-density lipoprotein
(LDL). Since cholesterol and other fats are insoluble in water, they require an aid to be
transported through the body. Therefore, Lipoproteins are formed in the liver to transport
cholesterol and other fats to the rest of the body cells. Cholesterol arte returned to the liver from
the body cells by another lipoproteins of high-density. Then it is secreted into the bile. Due to
diets high in diabetes and saturated fats, cholesterol levels become abnormal. Good cholesterol
which should be higher in number is called HDL while bad cholesterol which should be low in
number is referred to as LDL.
Elevated platelets- Considering that platelets are produced by the bone marrow, Scott’s
condition, his atrial fibrillation may result in the production of excess number of platelets. The
production of excess platelets leads to clotting. This makes Scott at more risk for a blood clot.
Carotid artery blockage- - Once the carotid arteries are filled with the plaque, they
become narrowed. Since the plaque is made up of cholesterol and fat, the deposition of these
components to the arteries hardens them making it difficult to deliver oxygenated blood to the
brain. This increases the risk of stroke.
Left MCA infarct- In Scott’s case, a portion of blood clot that had moved from the aorta,
had blocked the blood flow to the left cerebral artery. This caused a stroke and infarction as well.
Since the oxygenated blood is not able to get to the brain as it should in normal cases, the tissues
become infarcted or even die. In a stroke, there is no production of oxidative phosphylation
which produces energy. Additionally, the cell membrane get altered to allow depolarization
which allows calcium to move into the cell. There is the release of glutamate which causes
abnormal membrane permeability. This allows potassium, sodium and calcium to move into the
cell resulting in cellular edema. This decreases the PH inside and outside hence cause loss of
autoregulation. CT scan reveals whether there is a bleed present or not in order to determine
whether a person is hemorrhaging.
Elevated blood glucose- Scott has a BMI of 26.1. This indicates that he has obesity. In
this state, the individual has impaired control of glucose secretion. This increases the levels of
glucose in the blood. Again, after a stroke, the blood sugar tends to increase due to stress.
Additionally, Scott has type 11 diabetes which occurs when fatty acids increases in the blood.
This condition reduces the production of pancreatic B cells which are responsible for secretion of
This leads to a decrease in the release of insulin and an increase in production of glucose
from the liver. Nursing & Medical Management

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