NURS-6512N Week 3: Case Study Assignment: Differential Diagnoses and Diagnostic Testing of a 92-Year-Old African American Male
Assignment: Diagnostic Reasoning
Include the following:
- Identify the patient’s chief complaint.
- Identify what physical exams and diagnostic tests would be most appropriate to gather more information about the patient’s condition. Be specific and explain your reasoning.
- Explain how the results would be used to make a diagnosis.
- Identify three to five (3–5) possible conditions that may be considered in a differential diagnosis for the patient. Explain your thinking.
Case Study Assignment: Differential Diagnoses and Diagnostic Testing of a 92-Year-Old African American Male
Hypertension is one of the most common non-communicable lifestyle diseases that usually affect persons as they grow older. One of the causes is the inevitable stiffening of the walls of blood vessels through calcification as one ages. Combined with atherosclerosis due to hyperlipidemia, this is because of the higher prevalence of hypertension in the older generation (Barrett et al., 2019; Jameson et al., 2022). The patient discussed in this case is an elderly African American male with a history of hypertension who is non-compliant with taking his medications. On admission to the Emergency Department (ED), his BP is found to be high at 210/ 100 mmHg. The patient was brought by his daughter to the ED, and he presented with slurred speech. According to the Mayo Clinic (2022), dysarthria is a primary symptomatic indication of hemorrhagic stroke that affects the right side of the brain. Dysarthria is a disturbance in spoken speech by the patient as the speech center is impaired by the blood that infiltrates the brain parenchyma after a hemorrhagic stroke occurs. The patient high blood pressure could likely have been caused by non-adherence to his prescription or the ineffectiveness of the current medications he is on.
Background
Dysarthria is caused when neurons that send signals to control the tongue, face, and throat muscles are affected. Therefore, the muscles in these places become poorly coordinated due to the deranged neuronal signaling and weak and slow response (Barrett et al., 2019; Chiaramonte & Vecchio, 2020). The patient’s speech, affected by dysarthria, becomes slurred, slow, and incomprehensible. The increased blood pressure increases artery pressure in the brain, causing them to burst, resulting in hemorrhagic strokes. The neurons in the speech center get compromised; hence, they cannot effectively send nerve impulses to the neuromuscular junction for adequate movement required for speech.
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Convenient Diagnostic Tests and Physical Examination for the 92-Year-Old Patient
The brain has membranes that coordinate and send messages regulating our functions. The brain parenchyma is referred to as subarachnoid hemorrhage or SAH. However, another type of hemorrhagic stroke affects the actual brain parenchyma and, by extension, the speech center and is referred to as intracerebral hemorrhage or ICH (Barrett et al., 2019; Jameson et al., 2022). In this case, it is most likely that the type of hemorrhagic stroke he suffered from was the ICH type. Ball et al. (2023). A physical assessment, including a neuro assessment, is essential to focus on during patient systems assessment.
The neurologic examination will not stop at that but will also assess several neurological signs. A patient who has suffered a hemorrhagic stroke such as this one will usually also display signs that indicate meningeal irritation in the absence of inflammation. These signs indicate meningeal irritation, called meningism (Ball et al., 2023; McCance & Huether, 2019). In this case, a positive Kernig sign and a positive Brudzinski sign indicate the presence of meningismus or nuchal rigidity. A positive Brudzinski sign is elicited when hip flexion is not voluntary as the patient’s neck flexes. On the other hand, pain when the knee is extended as the thigh is bent at an angle of 90 degrees indicates a positive Kernig sign. Other appropriate tests for this patient include an electroencephalogram or EEG, an electrocardiogram or EKG, a chest X-ray, a computed tomography (CT) scan of the brain, and a magnetic resonance image (MRI) Differential Diagnoses and Diagnostic Testing of a 92-Year-Old African American Male.
Regarding imaging studies and evidence-based practice (EBP), a CT scan and an MRI should be the first imaging done. In this case, a CT scan gives the neurologist a much broader picture of any brain damage that this patient may have suffered. CT cans are more conclusive in detecting any bleeding in the brain. In this case, An MRI will also be helpful. Apart from the primary hemorrhage, there will also be subsequent hemorrhages in the form of abnormalities such as cerebral vein thrombosis and cavernomas, amongst others. An MRI will help detect any persistent bleeding, as well as surgeries and treatment plans.
Other Laboratory Blood Tests
Apart from suffering from hypertension, the patient could also be suffering from a variety of coagulation abnormalities and hemorrhagic conditions. Specific blood tests must also be done to measure these and rule them out in the patient. These include prothrombin time or PT (which can be translated to the international normalized ratio or INR), platelet count, and the activated partial thromboplastin time or aPTT amongst others (Jameson et al., 2022; McCance & Huether, 2019). The presence of thyroid antibodies, immunoglobulins, antinuclear antibodies, and the rheumatoid factor must also be quantitatively assessed. This is to rule out other conditions, such as vasculitis. Lastly, liver function tests and a renal profile may have to be performed as well to rule out kidney and liver failure Differential Diagnoses and Diagnostic Testing of a 92-Year-Old African American Male.
Employment of the Tests to Make a Diagnosis
The above tests and investigations would show that this patient has a diagnosis of hemorrhagic stroke. The impaired speech and the elevated blood pressure on assessment also support this diagnosis. Positive aPTT, PT, and INR tests would also point to a disorder of clotting that may have supported the hypertension in causing the stroke. The outcomes of these various tests and evaluations will be interpreted in light of the subjective information already in the clinician’s hands.
The Most Probable Differential Diagnoses for the Patient
According to the Mayo Clinic (2022) and Jameson et al. (2022), the other conditions that may also cause dysarthria and get mistaken for hemorrhagic stroke (differential diagnoses) include:
- Transient ischemic attack (TIA).
- Hypertensive encephalopathy.
- Amyotrophic lateral sclerosis or ALS.
The thinking behind this is that these conditions would cause similar dysarthria. Differential Diagnoses and Diagnostic Testing of a 92-Year-Old African American Male
References
Ball, J., Dains, J.E., Flynn, J.A., Solomon, B.S., & Stewart, R.W. (2023). Seidel’s guide to physical examination: An interprofessional approach, 10th ed. Elsevier.
Barrett, K.E., Barman, S.M., Brooks, H.L., & Yuan, J. (Eds) (2019). Ganong’s review of medical physiology, 26th ed. McGraw-Hill Education.
Chiaramonte, R., & Vecchio, M. (2020). A systematic review of measures of dysarthria severity in stroke patients. PM&R, 13(3), 314-324. https://doi.org/10.1002/pmrj.12469
Jameson, J.L., Fauci, A.S., Kasper, D.L., Hauser, S.L., Longo, D.L., & Loscalzo, J. (Eds) (2022). Harrison’s Principles of Internal Medicine, 21st ed. McGraw-Hill Education.
Mayo Clinic (2022, May 17). Dysarthria. https://www.mayoclinic.org/diseases-conditions/dysarthria/symptoms-causes/syc-20371994
McCance, K.L. & Huether, S.E. (2019). Pathophysiology: The biologic basis for disease in adults and children, 8th ed. Mosby/Elsevier. Differential Diagnoses and Diagnostic Testing of a 92-Year-Old African American Male
