Nervous System Case Study
History
A 73-year-old female
is brought to the ER via ambulance. She
is found lying on the floor of her kitchen by her daughter. Patient is awake but unable to speak or move
her right extremities. Daughter reports
she has witnessed her mother have two short spells of numbness and clumsiness
with her right hand over the past 3 months.
She urged her mother to see her family physician but does not believe
she has followed through. Medication for
hypertension and nonsteroidal anti-inflammatory drugs (NSAIDS)
for arthritis were brought to the ER
by the daughter, who states she believes her mother is hoarding her medication
and not taking it as often as prescribed.
Past
Medication History
Hypertension, arthritis
in left hip requiring use of quad cane for walking long distances; had a hysterectomy at age 46 for endometriosis
Family and
Social History
Patient is
widowed and lives alone. She is a
retired school bus driver. Daughter
reports she is active in her church and tends a large vegetable garden each
year. Multiple family members are
hypertensive, but history is negative for neurological
diseases.
Physical
Examination
Patient is
awake and calm. She is unable to answer
any questions and does not follow any commands for moving right extremities and
does not spontaneously move right extremities.
Follows all commands with left extremities, and muscle strength appears
normal for her age. Her blood pressure
was 168/108.
Diagnostic
Imaging
MRI of head
shows area of hemorrhage in the cerebral area on left side of
brain. X-rays of head, spine, and hips
were negative for fractures.
Diagnosis
Left CVA with right
hemiplegia
Plan of
Treatment
1.
Admit
to ICU and monitor for additional bleeding and worsening of symptoms.
2.
Aggressive
medical treatment to reduce blood pressure.
3.
Begin
rehabilitation with PT, OT, and speech therapy.
4. 4. Referral to medical social worker to
begin discussions with patient, family, and rehabilitation therapists to
determine alternate living arrangements.
Please answer the following
questions regarding this case study. This
is an opportunity to see how Med Term will be used in realistic events in the
healthcare field. To answers some
questions, you may need to use information from other chapters, in a medical
dictionary, or online.
1.
Pick
out at least five bolded medical terminology words from the case study and
dissect them into their prefixes, suffixes and/or combining forms/word roots.
Define each element and then define the whole word. See one example done for
you.
Example: Arthritis
Prefix:
Word Root:
arthr (joint)
Suffix: -itis (inflammation)
Whole word
meaning: Inflammation of the joints.
A.
B.
C.
D.
E.
2. Name and
define the following abbreviations used in this medical record:
ER
MRI
ICU
PT
OT
CVA
3. Do you think
taking skeletal x-rays was a necessary part of this patient’s evaluation? Why or why not?
4. In the ER
the patient was(A) unable to speak and (B)move the left extremities. What are the medical terms for each of these
symptoms?
A.
B.
5. Explain why
bleeding was found on the left side of the brain, but paralysis was on the right
extremities? Use proper med term to
explain.
