CAPSTONE PRESENTATION NURS 768: PRIMARY CARE III. Chu, Wai Ling Kennis , GNP/ANP Student Spring 2011. CC: Seizure and LOC
NURS 768: PRIMARY CARE III
Chu, Wai Ling Kennis, GNP/ANP Student
H&P: 71 yrs old white male had body shaking x 3 mins, was unresponsive, and had blood coming out of his month while he was sleeping, witnessed by his wife. Pt LOC for 30 mins, woke up spontaneously in ambulance with unclear voice asking “where am I going”. He denies nightmare, no history of seizure or head trauma, had flu-like symptoms x 2 weeks with no fever, symptoms relieved by OTC medicine, no change in old meds. Upon admission, Ativan 2 mg given. In the ER, pt has 2 episodes of left arm jerking together with his HR slow down to 30 bmp & asystole for 1 sec, BP 110/45 mmHg while he was snoring. He responds to tactile stimulus and wakes up immediately, denies numbness or abnormal feeling before and after the jerking.
15.1 143 103 14
7.2 44.2 137 5.5 19 1.0 208
Cal 9.9, Mg 2.5, Troponin I <0.012, CK-MB 1.3, Total CK 104
EKG:Regular sinus rhythm with prolonged QT interval 0.48 second.
Chest X-ray: Unremarkable
Head CT w/o contrast: Unremarkable. No evidence of cerebral infarct or hemorrhage.
Blood culture and urine culture:Results are pending.
Epileptic seizure:A transient occurrence of S&S such as limb-shaking due to abnormally excessive neuronal activity of the brain. It is associated with a prior CNS insult such as infection, stroke, brain trauma, etc. or an unknown etiology (AlEissa & Benbadis, 2011). In temporal or frontal lobe seizures, ictalbradycardia and asystole might occur (Maromi, 2009). After a grand mal seizure, CK levels are often elevated and remain for several hours or a day (Nguyen & Kaplan, 2010).
Rule In: Tongue biting, LOC, bradycardia and asystole.
Rule Out:Normal WBC & CK level, no fever, no aura, no incontinence, unremarkable head CT, no history of head trauma, seizure, or stroke, symptoms less than 24 hours.
Transient Ischemic Attacks: TIAs may be mistaken for seizures, but may also induce seizures. Brain ischemia reduced neural activity causing sensory loss, muscle weakness & numbness, trouble speaking. TIAs does not cause brain tissue to die and it does not show changes on CT or MRI scans. It is caused by temporary loss of blood flow to the brain due to a blood clot. The blockage breaks up quickly and dissolves. The causes of TIA include A. fib, polycythemia, inflammation of the arteries in the brain, risk factors include HTN, smoking, DM (Zieve & Hoch, 2010).
Rule In:Unclear speech, hx of HTN, CAD and old age.
Rule Out:Negative muscle weakness, numbness, sensory intact, no indication of hypercoagulation, no hx of a. fib. Low Stroke Scale Score.
Brain Neoplasm:About 1/3 of people with a brain tumor are not aware until they have a seizure. Seizures are caused by a disruption in the normal flow of electricity in the brain by the tumor. Other symptoms include headache, mental or personality change, focal symptoms such as hearing problem, double vision, decrease sensation, muscle weakness (ABTA, 2010). Brain tumors are more common in white males and usually detected in the old age. Risk factors including radiation, chemical exposure, hx or family hx of gliomas(National Cancer insitute, 2008).
Rule In: Seizure, old age, white male.
Rule Out: No focal deficit, no headache or personality change, negative head CT scan, no hx of excessive radiation or chemical exposure.
Meningitis/Encephalitis: They are infections in the brain and spinal cord caused by bacterial, viral, fungal infection; inflammatory diseases such as lupus; cancer or head and spine injury. Meningitis/Encephalitis cause dangerous inflammation which can produce a wide range of symptoms including flu-like symptoms, nausea, vomiting, confusion, photophobia and seizures (NINDS, 2011). The classic meningitis triad of fever, headache, and nuchal rigidity develops over hours or days (Merck & Co, 2011).
Rule In: Recent flu-like symptoms, seizure activity
Rule Out: No fever, headache, or nuchal rigidity, no complaint of confusion or photophobia, WBC negative, improved flu-like symptoms.
Convulsive Syncope: Syncope is commonly misdiagnosed as epilepsy because in conventional teaching, syncope are limp motionless events, in fact, it frequently involves brief body jerks (Benbadis, 2009). Syncope is an abrupt loss of consciousness because of the reduction of cerebral perfusion and cerebral hypoxia. In syncope, CK level rarely elevated, unless patient had a MI (Nguyen & Kaplan, 2010). A variety of cardiovascular disorders such as vasovagal syndrome, MI and arrhythmia can cause the sudden fall in cerebral perfusion by decrease cardiac output. Other causes including CVA, drug effects, electrolyte imbalance, anemia, hypoglycemia and dehydration (AlEissa & Benbadis, 2011).
“Many patients who have a single seizure do not require anticonvulsant therapy…This decision is based on a discussion of the risk of seizure recurrence, the effectiveness of anticonvulsant treatment, and the adverse medical and socioeconomic effects of anticonvulsant treatment” (AlEissa and Benbadis, 2011).
AlEissa, E, I, MBBS, MD & Bebadis S, R, MD (Jan, 2011). First seizure in adulthood. Retrieved March 06, 2011 from http://emedicine.medscape.com/article/1186214-print
American Brain Tumor Association. (2010). Seizures. Retrieved March 14, 2011 from http://www.abta.org/
Benbadis, S. (2009). The differential diagnosis of epilepsy: A critical review. Retrieved March 18, 2011 from http://www.epilepsyfoundation.org
Boggs, J. G. (2010). Seizures and epilepsy in the elderly: Etiology, clinical presentation, and differential diagnosis. Retrieved March 12, 2011 from http://www.uptodate.com.
Centers for Disease Control and Prevention. (2011). Healthy Weight – it’s not a diet, it’s a lifestyle. Retrieved April 05, 2011 from http://www.cdc.gov/healthyweight/
Deglin, J.H. & Vallerand, A. H. (2010). Nursing Central from Unbound Medicine handheld platform. Davis’s Drug Guide, 2010. [PDA Software]. Philadelphia, PA: F. A. Davis Company.
Epocrates. (2011). Epocrates Essentials: Version 3.16. Horizon BCBSNJ Classic-PDL. [PDA Software]. BMJ Publishing Group Ltd.
Folstein, M.F., Folstein, S., & McHugh, P.R. (1975). “Mini-mental state": A practical method for grading cognitive state of patients for the clinician. Retrieved February 22, 2010 from http://utswfm.googlepages.com/NH_MMSE.pdf.
Harrigan, R.A., & Chan, T.C., & Moonblatt, S., & Vilke, G.M., & Ufberg, J.W. (2007). Temporary transvernous pacemaker placement in the Emergency Department. Retrieved April 03, 2011 from http://www.ncbi.nlm.nih.gov/pubmed/
Kanjwal, K., Karabin, B., Kanjwal, Y., & Grubb, B.P. (2009). Differentiation of convulsive syncope from epilepsy with an implantable loop recorder. Retrieved April 02, 2011 from http://www.medsci.org/v06p0296.pdf
Maromi, N, MD. (2009). “Cardiac effects of seizures”. Retrieved March 11, 2011 from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2728482/
Mathur, R.M.D., & Shiel, W. C. M.D, FACP, FACR. (2009). Hemoglobin A1c Test. Retrieved April 03, 2011 from http://www.medicinenet.com/hemoglobin_a1c_test/article.htm
Merck & Co., Inc. (2011). Nursing Central from Unbound Medicine handheld platform. The Merck Manual, Professional edition,2011. [PDA Software]. Philadelphia, PA:F.A. Davis Company.
Minczak, B.M., MD, PhD. (2007). Seizures – What is the mechanism underlying clinical manifestations of seizure activity as seen in the ED? Retrieved April 08, 2011 from http://acep.org.content.aspx?id=33508
National Cancer Institute. (2008). Brain tumor. Retrieved April 3, 2011 from http://www.medicinenet.com
National Institute of Neurological Disorders and Stroke. (2011). Meningitis and Encephalitis Fact Sheet. Retrieved March 18, 2011 from http://www.ninds.nih.gov
National Kidney Foundation. (2011). Glomerular Filtration Rate (GFR). Retrieved April 03, 2011 from http://www.kidney.org/kidneydisease/ckd/knowgfr.cfm
Nei, M., MD. (2009). Current review in clinical science: Cardiac effects of seizures. Retrieved March 11, 2011 from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2728482/
Nguyen, T. T., & Kaplan, P. W. (2010). Nonepileptic paroxysmal disorders in adolescents and adults. Retrieved March 21, 2011 from www.uptodate.com.
Sovari, A.A., & Kocheril, A. G. (2010). Long QT Syndrome. Retrieved March 11, 2011 from http://emedicine.medscape.com/article/157826-print
Stoppler, M.C., MD., & Shiel, W. C., MD, FACP, FACR. (2008). Hyperkalemia (High blood potassium). Retrieved April 03, 2011 from http://www.medicinenet.com
U.S. National Library of Medicine (NLM), (2011). Hypercholesterolemia. Retrieved April 05,
2011 from http://ghr.nlm.nih.gov/condition/hypercholesterolemia
Venes, D. M.D. (2009). Nursing Central from Unbound Medicine handheld platform. Taber’s cyclopedic medical dictionary, 21st Edition. [PDA Software]. Philadelphia, PA: F.A. Davis Company.
Zieve, D, MD, MHA., & Hoch, D. B., PhD, MD. (2010). Transient ischemic attack. Retrieved
March 19, 2011 from http://www.nlm.nih.gov/medlineplus/ency/article/000730.htm.