[Solved]: A 78 y/o male patient with PMH significant for…

A 78 y/o male patient with PMH significant for hypertension (lisinopril/ hydrochlorothiazide daily) hyperlipidemia (atorvastatin daily), and aortic stenosis with subsequent mechanical aortic valve replacement (Warfarin for CVA prophylaxis), presents to the ED with new-onset confusion and gait disturbance. According to the patient’s wife, the patient suffered a fall 3 days ago while clearing snow from his driveway. The patient struck his head and has complained of a headache since the event, but has declined to seek medical attention until now. The patient’s vital signs on presentation are as follows: BP 160/90, HR 90, RR 22, Temp 98.2F Upon your exam, you find the patient to be oriented to person, but is unable to answer with the correct date, time, or location. His pupils are equal, round, reactive to light, and accommodate appropriately. His motor and sensory function is grossly equal bilaterally. 1.) What initial diagnostics would be appropriate in this patient’s case? STAT Head CT reveals large right-sided subdural hematoma with subsequent 4mm midline shift, with no evidence of large-vessel occlusion or aneurysm on CTA). The patient is admitted to the ICU under the care of the trauma and neurosurgery services, with the plan for follow-up head CT in 6hrs. The patient’s initial labwork is significant for INR 3.0 and serum sodium level 130. 2.) Please compare and contrast the pathophysiology and presentation of subdural, epidural, and subarachnoid ICH. Upon arrival to the ICU, the patient’s neurological status is unchanged, and his blood pressure (which briefly improved after a dose of 10mg IV Labetalol in the ED) is again elevated: 163/92. 3.) What medication orders should the nurse advocate for in order to provide optimal care to this patient? 4.) What non-pharmacologic interventions can the RN expect to perform in order to optimize the patient’s likelihood of a successful recovery? The scheduled repeat head CT is unchanged from the previous exam, and the patient’s hourly neurologic exams reveal no new deficits or evidence of further decline. His blood pressure remains well-within prescribed parameters on a low-dose Nicardipine infusion, and his repeat INR and serum sodium levels are 1.5 and 135, respectively. In the morning, the patient is taken to the OR for evacuation of subdural hematoma and placement of an ICP monitor. The patient returns to the ICU post-operatively extubated, with a stable neurological exam. His BP is 130/80 on the Nicardipine infusion, with an ICP of 12. 5.) Please calculate the patient’s cerebral perfusion pressure? What is the significance of this value in the patient’s treatment plan? The patient’s mental status continues to improve as a result of the exemplary care provided by the multidisciplinary team in the ICU. Three days after the hematoma evacuation, the patient returns to the OR for removal of the ICP monitor and embolization of the middle meningeal artery (MMA). As the patient is being prepared for discharge three days later, he suddenly suffers from a left-sided facial droop, dysarthria, and left-sided hemiparesis. STAT CT/ CTA brain reveals expected post-operative changes (markedly decreased SDH and resolved midline shift), in addition to a new right MCA occlusion. 6.) What risk factors likely predisposed this patient to this new ischemic stroke, and what treatments would help to restore function while mitigating associated risks? The patient undergoes an emergent right MCA thrombectomy with successful resolution of his symptoms. Close coordination of care between the neurosurgery and cardiology teams is required to determine the appropriate anticoagulation strategy moving forward, and the patient is discharged home 1 week later with no neurologic deficits and a plan for close follow-up.