Case Study Traumatic Brain Injury

Running head: TRAUMATC BRAIN INJURY 1

Case Study: Traumatic Brain Injury

Name of Student

Name of Institution

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Traumatic Brain Injury

Introduction

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

minutes.

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Measurements

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

Echocardiogram

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

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LDL: 138* <130 mg/dL

HDL: 25* 30-75 mg/dL

Cholesterol (total): 212* <200 mg/dL

Troponin

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

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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

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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

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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.

Symptoms

History and Physical Assessment

• Severe headache

• Confusion

• Dysphagia

• Aphasia.

• 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

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• 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

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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

memories.

• 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.

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• 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.

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• 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

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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.

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• 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

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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.

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This condition reduces the production of pancreatic B cells which are responsible for secretion of

insulin.

• 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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Case Study Traumatic Brain Injury

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