Integrated Case Test: April 14, 2021
Course: MICN 301 Time allowed: 45 minutes total
Case Presentation
Alice Ruhata, a 34 year old mother of three, has recently given birth to her third child and is 18 days postpartum. She lives with her partner, Joseph, and their two older children aged 5 and 2, in a poorly-heated two-bedroom house in Wellington.
Alice has a past history of Type 2 diabetes and hypertension, both of which have been difficult to control throughout her last two pregnancies. She was commenced on metformin (an oral anti-glycemic agent) and methyldopa (an anti-hypertensive agent) during the second pregnancy. Alice has always struggled with her weight but managed to give up smoking during her second pregnancy and has a 5 pack year history. With the most recent pregnancy, Alice developed preeclampsia with worsening hypertension and oedema, leading to the infant’s birth by Caesarean section two weeks early, at 38 weeks gestation. Other past history includes deep vein thrombosis following her second pregnancy which resolved following anticoagulant therapy.
Today, Alice’s mother, Rewa, who has come to help out with her mokopuna, discovers Alice slumped over a bean bag on the lounge floor. Alice seems unaware of her surroundings and Rewa can’t make any sense of what Alice is saying. Frightened, Rewa calls Joseph at work who suggests calling an ambulance immediately.
Question 1 (25 minutes)
(a) Suggest four (4) potential causes for Alice’s collapse. For each of your four suggestions, discuss the features of Alice’s presentation that would lend support to your hypothesis.
Ischaemic stroke Limb weakness, slurred speech, confusion, are classical features of stroke. additionally alice has diabetes, hypertension, smoking, and struggles with weight. additionally preeclapmsia can lead lasting damage
seizure fallen over, cant move, slurred speech could be a absence seizure or postictal phase
cerebral haemorrhage the hypertension may have lead to a cerebral haemorrhage. cerebral haemorrhage can lead to slurred speech and confusion
hypoglycaemic episode syncope and confusion/slurred speech could be a severe hypoglycaemic episode. alice has diabetes which lends itself to this
(b) Name two (2) important considerations in the management of Alice in the acute phase of her presentation if stroke is suspected. Provide a brief rationale for each.
due to surgery still healing fibrinolytics should not be administered as the risk of haemorrhage is high also give paracetamol and especially insulin as might blood sugar and temperature is associated with poor outcomes. however her state of a diabetic might make this more difficult with her not responding to insulin or it interfereing with metformin
**it is important to stabilise the patients vitals (including LOC), and glood levels, as well as determining stroke type as well as **
Clinical Update
Joseph joins Alice in the Emergency Department and is able to answer the ED doctors’ questions. The following information is ascertained about Alice’s status: 34 year old female presenting 18 days postpartum following C-section for worsening preeclampsia. Husband says she has been complaining of headaches and nausea for two days and vomited three times yesterday. This morning she complained of worsening headache, dizziness and blurred vision. Husband thought she could have the flu but saw she had been walking ‘a bit wonky’ (?gait disturbance) for the past day or two, so arranged for grandmother to be with her and the children today. Paramedics report patient drowsy and confused (thought she was “going to hospital to have the baby”).
On examination by the House Surgeon: Patient rousable and cooperative but some inappropriate replies to questions. GCS 13 (E3V4M6). Able to walk but ataxic.
Vital Signs:
- BP: 180/92
- Pulse: 104 b/min and regular (sinus tachycardia)
- O2 saturation: 95% on room air
Neurological:
- Both pupils equal, reacting to light and accommodating (PERLA)
- Bilateral vertical gaze palsy (failure of upward gaze) with some vertical nystagmus. Internuclear opthalmoplegia (disorder of conjugate gaze affecting horizontal eye movement)
- No facial asymmetry
- Power, tone, sensation and reflexes all normal. Bilateral down-going plantar responses
- No fine tremor noted
(c) Name three (3) further bedside examinations/bedside tests you would perform if you were the house surgeon and for each, state how either a positive or a negative result could help you towards establishing a diagnosis.
point of care blood glucose monitor.
- rule out hypoglycaemic episode or epilepsy if negative.
check for papilloedema to look for ICP. This could confirm give a reason for ICP like symptoms (vomiting dizziness headache) and let the team look for reasons for ICP
full neuroexam. We need to check brainstem sensation and motor capacity t
(d) Name two (2) radiological investigations apart from CT that could enable a definitive neurological diagnosis.
MRI
Xray with angiography
Question 2 (10 minutes)
A CT scan of Alice’s head revealed an area of low attenuation within the left thalamus extending towards the midline and close to the third ventricle, representing an acute ischaemic thalamic infarct.
(a) Explain how an acute ischemic infarct produces an area of low attenuation (hypodensity) on CT.
Blood is hyperdense compared to brain tissue. this means a significant portion of radioopaqcity comes from blood perfusing the brain tissue. This means that if blood flow is stopped, as in an ischaemic stroke, it will become relativly less dense than surrounding tissue
(b) Provide a cellular mechanism for cerebral ischaemia leading to cerebral infarction and neuronal cell death.
cerebral ischaemia means no blood flow. no blood flow means no oxygen. no oxygen means no oxidative phosphoyrlation. no oxidative phosphorylation means no atp no atp means no cellular work no callular work means no maintainence of transmembrane potential,
Question 3 (5 minutes)
Alice and Joseph’s 2 year-old son, Levi, comes with Joseph to visit his mother in hospital. She is making a satisfactory recovery after following swift medical intervention and has her new baby ‘rooming in’ with her.
The nurse observes that when she (the nurse) talks to Levi he doesn’t answer her. He communicates with his father by tugging at his father’s hand and whining, more than actually talking. His father seems unconcerned when the nurse queries Levi’s restricted communication and says “that’s just Levi’s way”.
(a) With reference to normal developmental milestones in a two year-old, give two (2) possible reasons for Levi’s behaviour, briefly providing your reasoning for each.
by 2 years old the child should know 200-300 words and talk in 2-3 word sentences. This means that there is delay. This can be for a number of reasons but a large one is childhood deafness. Its hard to learn a language when you can barely hear it. The child could also have autism, and by non verbal, as that would explain lack of speech and lack of response to fathers questioning
Answers
Question 1
(a) Four potential causes and supporting features: (Any four of the following are acceptable)
- Ischemic Stroke: She has multiple risk factors (preeclampsia, hypertension, type 2 diabetes, obesity, past smoker). Pregnancy increases risk due to hormonal changes. She is predisposed to hypercoagulability (previous VTE).
- Hemorrhagic Stroke: Risk factors as above (hypertension, preeclampsia, diabetes).
- ==Postpartum Preeclampsia: History of difficult-to-control blood pressure and diabetes, overweight, recent severe preeclampsia requiring early C-section.==
- Cerebral Venous Thrombosis (CVT): Hypercoagulable state (previous VTE, postpartum). Potential dehydration from osmotic diuresis (diabetes) and breastfeeding.
- Hypoglycemic episode: On metformin. Skipping meals due to rigors of new baby. Breastfeeding adds to metabolic demand. Decreased LOC and incomprehensible speech fit this.
- ==Sepsis: 18 days postpartum post-C-section. Overcrowded/cold house. Diabetics are predisposed to infection==.
(b) Two important considerations in acute stroke management:
- Manage airway (NBM): Rationale: She has a reduced LOC. Important to maintain patency, ensure oxygenation, and prevent aspiration (keep Nil By Mouth).
- Frequent Neurological Checks (GCS): Rationale: If hemorrhagic, she could deteriorate rapidly. Frequent monitoring detects changes early.
- (Alternative) Control BP and Blood Glucose: Rationale: Poor control significantly impacts stroke prognosis.
- (Alternative) Urgent Head CT: Rationale: Must establish if it is ischemic or hemorrhagic to guide treatment.
(c) Further bedside tests/examinations:
- Blood glucose level: High indicates poor diabetes control; very low points to hypoglycemia as cause of collapse.
- ==Temperature: If pyrexic, points to sepsis/infection. If apyrexic, infection unlikely.==
- ==Urinalysis: Check for glucose, protein, ketones. Can rule in/out diabetes complications, preeclampsia (proteinuria), or infection==.
- Check optic discs (Fundoscopy): Bulging discs indicate raised ICP (SOL, hemorrhage, or PRES).
- Detailed cerebellar exam: Nose-to-finger, heel-to-shin to assess ataxia side/origin (cerebellar vs thalamic).
(d) Two radiological investigations (apart from CT):
- MRI (Magnetic Resonance Imaging)
- DWI (Diffusion-weighted imaging) (Also acceptable: Angiography, Perfusion scan, PET).
Question 2
(a) Low attenuation (hypodensity) on CT:
- Ischemia leads to failure of cell membranes and associated cellular edema (water accumulation). In the acute phase, this edema appears hypodense. If not relieved, tissue undergoes necrosis and liquefaction, assuming a water-like density, which appears dark (hypodense) on CT.
(b) Cellular mechanism for cerebral ischemia:
- Ischemia results in the failure of ATP-dependent ion pumps.
- This causes rapid redistribution of ions and release of excitatory neurotransmitters (glutamate).
- Excess glutamate binds NMDA/AMPA receptors, causing massive calcium influx and rapid depolarization (excitotoxicity).
- This triggers a cascade of neuronal toxicity and cell death via necrosis.
Question 3
(a) Possible reasons for 2-year-old Levi’s behaviour:
- Stranger Anxiety / Secure Attachment: Levi retreats to his father because he is securely attached, and the nurse is a stranger.
- Fatigue / Emotional regulation: He is adjusting to a new sibling, likely tired or jealous. 2-year-olds easily become frustrated and withdrawn when overwhelmed.
- Hearing deficit (Conductive): Living in a crowded, poorly heated home increases risk for recurrent otitis media (glue ear). At 2, he should have a 200-300 word vocabulary. Tugging/whining instead of speaking could indicate hearing loss.