A 40-year-old legally blind female presented with bilateral lower extremity weakness and inability to walk. She has a history of similar episodes since age 16 diagnosed as a demyelinating disorder. Her current presentation is her worst episode yet with more rapid progression of symptoms and new bowel incontinence. Imaging showed a T6 spinal cord lesion. Laboratory tests confirmed high aquaporin-4 antibody levels consistent with Neuromyelitis Optica Spectrum Disorder. The neurologist recommended additional treatments like Rituximab or plasma exchange but the patient wished to try steroids first.
SSPE, dr. amit vatkar, pediatric neurologistDr Amit Vatkar
Subacute sclerosing pan encephalitis (SSPE) also known as Dawson Disease, Dawson encephalitis, and measles encephalitis is a rare and chronic form of progressive brain inflammation caused by a persistent infection with measles virus.
In this presentaion i will a case a sspe and give u some information regarding daignosis and treatment
Dr. john millichap kcnq2 Cure summit professional track learn more at kcnq2cu...scottyandjim
Dr. John Millichap speaking at 2014 Denver KCNQ2 Cure summit professionals track at Children's Hospital of Colorado. More information at www.kcnq2cure.org
SSPE, dr. amit vatkar, pediatric neurologistDr Amit Vatkar
Subacute sclerosing pan encephalitis (SSPE) also known as Dawson Disease, Dawson encephalitis, and measles encephalitis is a rare and chronic form of progressive brain inflammation caused by a persistent infection with measles virus.
In this presentaion i will a case a sspe and give u some information regarding daignosis and treatment
Dr. john millichap kcnq2 Cure summit professional track learn more at kcnq2cu...scottyandjim
Dr. John Millichap speaking at 2014 Denver KCNQ2 Cure summit professionals track at Children's Hospital of Colorado. More information at www.kcnq2cure.org
Asthma is a lung disorder that interferes with breathing. It can cause serious, recurring episodes of wheezing and breathlessness, known as asthma attacks. The trouble stems from chronic inflammation in the tubes that carry air to the lungs. While there is no cure, there are highly effective strategies for keeping asthma symptoms at bay.
SubjectiveChief complaint headaches and blurriness of visi.docxpicklesvalery
Subjective:
Chief complaint: headaches and blurriness of vision on the right side
History of present illness: the patient is 67 years old Caucasian female, she complains of having had headaches for 2 weeks now. The pain is located in the right temporal area. She describes the pain as 8-10/10, sharp, constant, interferes with her sleep, she states that nothing aggravates it, not even the bright lights or high sounds, but she gets a little relief by taking Ibuprofen 800 mg. She stated that she has been having some blurriness in the right eye, while her left eye is fine. She also complains of pain in her jaw and tongue while chewing food. Her appetite has been low, and lost about 5 pounds in the last 2 weeks. She noticed low grade fever as well. She also reported ringing sounds in the right ear. She denies any nausea or vomiting. She denied having similar headaches in the past. The patient denies complaining of nasal or postnasal drainage.
PMH: past medical history is significant for Hypertension, type II diabetes mellitus, asthma, and degenerative arthritis of the knees.
PSH: hysterectomy
Medications: Lisinopril 10 mg PO QD
Metformin 500 mg PO BID.
Proair HFA 2 puffs PRN.
Ibuprofen 800 mg TID
Multivitamins
By comparing the medications that the patient is taking with Beers criteria, they all looked appropriate to be used in elderly patients.
Family Hx:
Father: HTN, diabetes, and stroke.
Mother: HTN, Diabetes, and breast cancer at the age of 72.
Social Hx: the patient never smoked tobacco products.
ETOH: social drinker
Illicit substances: denies ever using illicit drugs.
Allergies: penicillin.
Review of systems:
Constitutional: the patient complains of fever, fatigue, anorexia, and weight loss.
Head: the patient denies complaining dizziness or lightheadedness.
Eyes: blurriness in the right eye.
Ears: the patient reports tinnitus- right ear, but denies complaining of ear pain or ear discharge
Nose: the patient denies any nasal bleeding, discharge or obstruction
Mouth: the patient reports painful chewing, she denies gingival bleeding, having mouth sores, or having dental difficulties
Throat: no sore throat
Cardiovascular: the patient denies complaining of Chest pain, palpitations, or swelling in the legs.
Respiratory: the patient denies any wheezing, shortness of breath or coughing.
Gastrointestinal: the patient denies any nausea, vomiting, GERD, epigastric pain, diarrhea, constipation, having black stools, or blood in stool.
Genitourinary: the patient denies any dysuria, polyuria, or visible hematuria
Musculoskeletal: bilateral knee pain.
Integumentary (Skin): the patient denies having any skin rash or skin discolorations.
Neurological: the patient denies complaining of tingling or numbness in any extremity; there is no history of seizures, stroke, syncope, or memory changes.
Psychiatric: the patient denies complaining of depression, or anxiety, denies complaining of hallucinations.
Endocrine: the pat ...
Digital Clinical Experience Comprehensive (Head-to-Toe) Physi.docxmecklenburgstrelitzh
Digital Clinical Experience: Comprehensive (Head-to-Toe) Physical Assessment
Week 9 SOAP NOTE
Doris Ofodile
Walden University
Nurs 6512
Advanced Health Assessment & Diagnostic Reasoning
Dr Kristin Curcio
July 31st, 2022
Patient Initials: T.J Age: 28 Gender: Female
SUBJECTIVE DATA:
Chief Complaint (CC): " I came in because I'm required to have a recent physical exam for the
health insurance at my new job"
History of Present Illness (HPI): Miss Jones is currently employed by Smith, Steven, Stewart,
Silver & Company. Before she begins work, a pre-employment physical must be completed.
Despite having a history of type 2 diabetes, in which she is able to control it by taking metformin,
dieting, and doing physical activity. For the past 4-5 months, she has been compliant with
metformin. By eating yogurt, Metformin has no longer caused any side effects for her. The last
time she saw a doctor was for her gynecology appointment four months ago in which the doctor
prescribed oral birth control pills to her after she was diagnosed with the polycystic ovarian
syndrome. Although, according to her, she is in good health and does not have any acute health
issues, or stressful events, and is looking forward to starting her new job.
Medications: Metformin 850mg PO BID, the last dose taken this morning.
Fluticasone propionate (Flovent) was 110 milligrams twice daily.( taken last in
Albuterol (Proventil) 90mcg 2 puffs every four hours PRN.( taken three months )
Drospirenone/ethinyl estradiol (dosage unknown). It was taken this morning.
Tylenol 500 mg PO PRN for headache, medication was taken last week.
Ibuprofen 600mg PO TID PRN to alleviate period cramps, was taken six weeks ago.
Zantac was taken for GERD (completed)
Tetracycline was taken because of acne (completed)
Allergies: Miss Jones is allergic to penicillin which causes an allergic reaction characterized by
hives and a rash. She is also allergic to cats and dust which triggers an asthma attack causing her to
itch, wheeze and sneeze. She denies allergic reactions to latex and foods.
Past Medical History (PMH): During her second and a half years of life, Miss Jones was
diagnosed with asthma. Her medication regimen includes Proventil and Flovent.
A diagnosis of diabetes was made at the age of twenty-four. Metformin is the medication she uses
to manage her diabetes, but she had trouble complying because she had side effects like gassiness,
which was later relieved with yogurt. As a result, she is better able to monitor her blood sugar
levels daily, which last read at 90. The patient also reports losing 10 pounds in four months. Also,
she reported that she slipped and hit her right foot, resulting in a healed wound.
At the age of 28, she was diagnosed with the polycystic ovarian syndrome which she manages by
taking birth control pills. Miss Jone’s menstrual cycle flows for five days and is regular. No
Sexually transmitted diseases or pregnancies have been reported.
At 38.
Pharmacological management of cerebral vasospasm in subarachnoid hemorrhagePrisma Health Upstate
Medical management of vasospasm in subarachnoid hemorrhage patients. Despite targeting multiple pathophysiological mechanisms of DCI and vasospasm, most of the trials did not yield results that could translate to clinical practice. Fasudil and emerging therapies like cisternal irrigation and lumbar drainage combined with intrathecal vasodilators and phosphodiesterase medications showed promising results but need to be tested in a randomized clinical trial for effectiveness.
An overview of Decompression hemicraniectomy in patients with large hemispheric infarctions. The presentation touches upon definition, pathophysiology, medical management, rationale for surgery, mortality, functional outcomes of DHC, and complications in a nutshell.
Cryptogenic stroke and PFO have always been a controversial topic with no closure trial in the past showing significant benefit from closing the PFO in preventing the recurrent stroke. Also thought to be due to imperfect definition of cryptogenic stroke which is evolving with drop in the fraction of patients from 20-40% in the past to very fewer numbers due to increased understanding of the mechanisms involved in acute stroke. Recent trials REDUCE and CLOSE targeted the niche population of PFO with moderate to large shunt and atrial septal aneurysm and showed benefit of closing PFO compared to the antiplatelet therapy alone but with the risk of A.fib, device and procedure related complications. This presentation is made in the Cerebrovascular center weekly conference at the Cleveland Clinic with my perspective after these current trials.
Tenecteplase is a newer generation tissue plasminogen activator which can be given as a bolus dose than continuous infusion. Genentech, the same company that manufactures Alteplase makes Tenecteplase. Phase 2 RCTs have been done on Tenecteplase comparing its feasibility and safety against Alteplase and so far the studies have been encouraging. In a pooled meta analysis from the Australian TNKase trial and ATTEST trials, tenecteplase seems to be better in recanalizing LVO compared to Alteplase which also showed to improve functional outcome in the first 24hrs and 3 months mRS. But it is difficult to extrapolate the evidence into clinical practice yet as this is a very small number of patients and phase 3 RCTs will answer further questions. This tPA sibling to Alteplase is cheaper and widely available due to its use in Acute coronary syndrome management and its ease of administration demonstrate better profile. But as Genentech is the same company that manufactures both, there is skepticism that it will do any company led phase 3 RCTs to build the evidence for TNKase in Acute ischemic stroke as it is cheaper than Alteplase and they even increased the price of alteplase to >100% since its introduction into the market.
Case presentation at the Time Critical Diagnosis summit at Columbia, Missouri. Education conference for EMS, nurses and advance practice providers. 04-07-2017
RCVS is usually a benign cerebral vascular dysregulation induced clinico-radiological syndrome presents typically with recurrent thunderclap headache with or without ischemic/hemorrhagic stroke or cerebral edema with vasoconstriction. Various risk factors are responsible for this syndrome.
2. Weakness and numbness in bilateral
lower extremities and unable to walk
3. A 40 year old right handed legally blind female patient presented to the ER on
10/25/2014 with the chief complaint of Bilateral lower extremity weakness which
started a day before with flu like symptoms, back ache followed by tingling in the
right lower extremity and subsequently spread to the left lower extremity by next
morning with profound weakness and unable to use the lower extremities. Also
associated with bladder and bowel incontinence with bowel incontinence being new
to the patient. Uses crutches and power chair to ambulate at home but unable to
transfer from bed to chair since that day. Had a few falls in the process of
ambulation.
History of similar episodes in the past since the age of 16years with relapses of
these symptoms at least 1-3 times an year. Her last episode was in May, 2014.
At the age between 19-22 years old, she was paraplegic for several months and
became ambulatory after several months of physical therapy. Uneventful 2013 for
the patient with no flares and she delivered a healthy baby girl who is 8 months old
now.
All her relapses in the past were dramatically improved with high dose IV steroids for
3-5 days with oral taper with some residual deficits after every episode.
4. At baseline has urinary incontinence, stiffness in bilateral lower extremities with
spasms, patchy sensory loss in bilateral lower extremities.
She became blind in her left eye at the age of 3yrs and only had central vision in her
right eye. She had symptoms of chronic urinary tract infections and was on
intermittant antibiotics because of the incontinence
Recently had extraction of her wisdom tooth
According to the patient this is the worst episode in many years which is different
from the rest of the flares by the rapidity of progression of symptoms, intensity of
symptoms, development of bowel incontinence and intensity of back pain.
Was a Neurology patient since the age of 19years when she was diagnosed and most of
her initial workup was done in Des Mois, Iowa city and used to follow Dr. Lardizabal, MD
in Northeast Regional Hospital since 2007 then here in the University Hospital till 2014
and now established care with Dr. Chuquilin, MD and may be a Friday conference case
in the past too.
5. Ashthma
GERD
Neurogenic Bladder
Recurrent UTIs
Hypothyroidism
B12 deficiency
Polycystic Ovarian disease
Sister died at the age of 21 years, Blind since childhood, Unable to ambulate since the
age of 12-13 years and died of Pneumonia. Father died of Pancreatic cancer, Strong
family history of Lupus, Depression.
She lives with her daughter in Kirksville, MO. Doesn’t smoke, drink and denied any illicit
drug usage. Motivated to take care of her daughter, Didn’t work since childhood on
disability, Volunteered in the past in a Blind school in Iowa city. Had a Boyfriend in Iowa
city.
Allergic to Lovenox and Adhesive tape
7. Demyelinating disorders like Multiple Sclerosis/NMO/Transverse Myelitis
Autoimmune polyneuropathies like AIDP, GBS(unlikely due to Bowel involvement),
Vasculitis.
Infectious processes like Lyme’s disease, Tick paralysis, Sarcoidosis
Thoracic myelopathy secondary to compression: Epidural abscess, Tumor, AVM
Spinal cord infarction
8. Vitals:
▪ Temperature (Celsius) 36.1 Deg C
Heart Rate 84 bpm
Respiratory Rate 20 breaths/min
SBP NIBP 108 mmHg
DBP NIBP 73 mmHg
SpO2 100 %
GENERAL EXAMINATION
Patient in not apparent distress, cooperates with examination. Obese.
HEAD: normocephalic, atraumatic, no lesions or exudates.
EYES: normal.
EARS, NOSE AND THROAT: normal, no lesions or exudates.
NECK: supple, no lymphadenopathy or thyromegaly.
EXTREMITIES: no clubbing, edema or cyanosis.
9. MENTAL STATUS:
Patient was alert, awake and oriented x3, follows commands. Speech is fluent and comprehension is intact.
CRANIAL NERVES:
II: Visual fields were full, Fundoscopic exam showed pale optic disc bilaterally. Pupils were reactive to light and
accommodation. APD bilaterally with no INO.
III, IV, VI: Right eye exotropia. Nystagmus in all directions of gaze.
V: face sensation was normal to light touch and pinprick.
VII: face was symmetric. Eye closure and lip closure were normal.
VIII: hearing is intact.
IX-X: palate elevates at midline.
XI: shoulder shrug is 5/5 bilaterally.
XII: Tongue was midline and strong. No fasciculations.
MOTOR:
Normal strength 5/5 on MRC scale in the upper extremities.
Iliopsoas 0, hip abduction 0, hip adduction 1, quadriceps 2 on the right and 1 on the left, hamstring 2. Dorsiflexion
is 0 on the right side and 2 on the left side, plantar flexion is 0 on right side and 2 on the left side.
Spasticity both lower extremities
Fine finger movements were normal bilaterally. No pronator drift.
SENSATION:
Decreased pinprick below rib cage level and both lower extremities.
Vibration diminished in both the lower extremities up to knees. Strong on the right knee and absent on the left
knee
COORDINATION:
Absent dysmetria on finger -nose -finger. Normal rapid alternating movements. No tremor.
GAIT:
Wheelchair-bound
REFLEXES:
3+ biceps, triceps, 4+ at the knees and ankles with sustained clonus. Babinski was positive bilaterally
10. WBC – 9.0
HGB – 14.1
MCV – 87.8
PLT – 284
ESR – 23
Electrolytes – Normal
BUN – 11
Creat – 0.72
Vitamin B12 – 1124
Folate - >40
Vit – D – 26
TSH – 0.425 with normal T4
B2 – 23
UA – negative
Aquaporin-4 receptor antibody in serum – Later
17. >160 (Reference <4)
Previous CSF studies done in 2007 in Northeast
Regional Hospital – Positive antibody, negative
Oligoclonal bands, IgG or pleocytosis. On Rebif since
2007, tried Copaxone and Avonex in the past.
Disease not well controlled. Patient is afraid of port
placement and refused Plasma exchange and IVIg
treatments in the past multiple times.
Exam during the clinic visit is almost unchanged from
the hospital exam. Recommended Rituximab
infusions and Plasma exchange. She asked for 2
weeks of time hoping that steroids will work.