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CAPSTONE PRESENTATION NURS 768: PRIMARY CARE III. Chu, Wai Ling Kennis , GNP/ANP Student Spring 2011. CC: Seizure and LOC

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capstone presentation nurs 768 primary care iii
CAPSTONE PRESENTATION

NURS 768: PRIMARY CARE III

Chu, Wai Ling Kennis, GNP/ANP Student

Spring 2011

slide2

CC:Seizure and LOC

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.

slide3

PMH: HTN, Hypercholesterolemia, CAD

  • PSH:GABG
  • Allergy:NKA
  • Social Hx: Retired letter carrier, never smoke, drink a glass of wine after dinner occasionally, denies illegal drug use; no regular exercise, regular diet with night time snack.
  • Family Hx: Father, CHF; Mother, Stomach CA.
  • Immunizations:Pneumoncoccal in 2005, Influenza in 12/2010.
  • Screening test: Stress test in 02/2011, negative.
  • Medications: Atenolol 50 mg PO qd, ASA 81 mg PO qd, Zocor 40 mg PO qhs, Allegra 60 mg po and Afrin nasal sprays as needed.
slide4

Review of Systems

  • HEENT:Denies eye, ear, or nose problems, no headache or dizziness, mild sore tongue 20 to tongue bite during sleep, no sore throat or difficulty swallowing.
  • Resp: Denies trouble breathing, denies sleep apnea.
  • CV:No chest pain, pressure, no palpitation.
  • GI: Denies urinary or GI problem, no incontinence.
  • Musculoskeletal:Body shaking x 1, witnessed by wife.
  • Neuro: Denies weakness, numbness, incoordination, no fainting or memory loss; denies depression, insomnia, or sleeping problems.
slide5

Physical Exam

  • V/S :BP 123/88, HR 90, R24, T98.2 F, O2 Sat 95% with O2 3L n/c, fasting BS 128 mg/dl upon admission.
  • General Appearance: Tired looking, oriented x 3 except unable to recall what happened before he was in the ambulance. Ht 179 cm , Wt 216 lbs, BMI 31.9. Skin warm, no rashes or lesion.
  • HEENT:Normocephalic/atraumatic; PERRLA, EOMI, no nystagmus; normal hearing; no nasal discharges or sinus tenderness; mild ecchymotic abrasion noted in the left side of tongue, no swelling or active bleeding, gag reflex intact; throat pink, no exudates, mild slurred speech 20to tongue trauma, speech is articulate.
slide6

Physical Exam Cont’d

  • Resp: Normal breath sounds, no coughing, wheezing, rales, or stridor. Loud snoring observed when sleeping.
  • CV:Normal S1 & S2, no heart murmur, no JVD, no carotid bruit; no edema.
  • GI/GU:Abd soft, non-distended, non-tendered, no penile discharge, ulcers, mass or hernia.
  • Neuro:Cranial nerves I to XII grossly intact, no focal deficit, no tremor or seizure activities at most time except 2 episodes of left hand jerking during sleep; sensory intact, appropriate coordination, normal reflexes; no cognitive impairment. Mini-mental state exam score is 26 and NIH Modified Stroke Scale is 1.
diagnostic tests
Diagnostic Tests

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

UA:Negative

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.

slide8

Differential diagnosis & Pathophysiology

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.

causes of seizure in different age group
Causes of Seizure in Different Age group

Source: http://www.epilepsyadvocate.com.

slide10

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.

slide11

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.

slide12

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.

slide13

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).

Rule In

slide14

Why it is Convulsive Syncope?

  • A brief motor activity including tonic extension of the trunk and limbs or several clonic jerks can occur in uncomplicated syncope (Nguyen & Kaplan, 2010).
  • Unlike epilepsy, patients usually wake up quickly after a syncopal event (Nguyen & Kaplan, 2010). Despite the suspected episode of generalized tonic-clonic seizure prior to admission, this patient is easy arouse by tactile stimuli from the 2 seizure-like actitives.
  • Pt’s CK level within normal range
  • Pt’s hx of HTN, CAD, current sick sinus syndrome from regular sinus rhythm to bradycardia to asystole, prolonged QT interval, hyperkalemia, all of these put him on high risk of sudden fall in cerebral perfusion and syncope by decreased cardiac output.
slide15

“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).

slide16

Treatment Plan

  • Airway maintenance and seizure precaution
  • Ativan 2 mg IV q6hrs prn
  • 100% non-rebreather
  • Maintain cardiac output
  • External pacemaker
  • Transvenous pacemaker insertion
  • Close serum potassium and blood sugar monitoring
  • EEG monitoring & Neurologist consult
  • Weight loss and diet control
  • Regular exercise
  • Patient and family education
slide17

References

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/

slide18

References

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

slide19

References

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.