8 Case Analysis 3: Ms. Armour’s Aching Head

Learning Objectives

Process Learning Objectives:

Through authentic practice and shared inquiry in this case, students will develop:

  • Information literacy skills, including the ability to locate, access, evaluate and use information in a wide range of situations.
  • Awareness of the role of emotions in learning.
  • Self-directed learning and metacognitive strategies to maximize their learning effectiveness.
  • Fluency in reading, writing, summarizing, speaking, listening, viewing and presenting information.
  • Social skills critical to effective team functioning, including interacting, cooperating, collaborating, and mutual respect for others’ ideas.

Content Learning Objectives:

Through authentic practice and shared inquiry in this case, students will develop a deep understanding of cerebrovascular accidents (CVA, stroke) including:

  • Etiology, symptoms and causes of cerebrovascular accidents (CVA, stroke)
  • Diagnosis and classification of cerebrovascular accidents (CVA, stroke)
  • Differentiation of hemorrhagic stroke from ischemic stroke
  • Effects of pregnancy on hypercoagulability
  • Diagnostic features of hemorrhagic and ischemic stroke on head CT
  • Management and treatment of hemorrhagic and ischemic stroke
  • Prevention of hemorrhagic and ischemic stroke
  • Outlook/Prognosis for those following cerebrovascular accidents (CVA, stroke)

The Case of Ms. Armour’s Aching Head

Ms. Charlayne V. Armour, a 36 year-old African-American woman with a past medical history of migraine with aura, arrives in the ED complaining of a left-sided headache that won’t go away. She is 8 days postpartum after delivering a normal baby boy at 34 weeks of gestation. The placenta was retained and was manually removed by the obstetrician one hour and twenty minutes after delivery. The placenta was examined and deemed complete. She had no further vaginal bleeding.  She rates her current pain level at a 9/10. The nurse takes the patient’s vital signs.

History and Assessment

Past Medical History

  • Gravid 6, Para 5
  • Gestational hypertension
  • Migraine with aura
  • No history of heart disease or other cardiovascular issues

Family History

Ms. Armour is married, and lives with her husband and 5 children, who are ages 16, 10, 6, 4 and 8 days. She is not taking any medications. She is an ex-smoker with an eight pack year history.

 

Immediate Assessment

  • BP 156/98 mmHg
  • Pulse 108/min
  • Respiratory rate 23/min
  • BMI 33 kg/m2

The nurse asks Ms. Armour if she has any blurred vision, has had any floaters, nausea or vomiting.

Ms. Armour reports that she has had nausea for 24 hours and has vomited 3 times. She has had some blurred vision with floaters. She reports that these symptoms are common with her migraines.

The nurse asks if she has had any sudden weight gain or swelling in the hands, feet or face.

Ms. Armour reports that her hands are swollen and she had to take off her rings.

Stop here!

Identify important observations and generate hypotheses based on your observations. Using numbers or arrows (or some other system), link each hypothesis to the observation(s) which support that hypothesis. What assessments/interventions should occur next in Ms. Armour’s care?

Begin your list of learning issues.

Dr. Evans, the emergency room attending physician, has performed an initial assessment.  She orders a Hematology Profile (HP), blood chemistries, coagulation panel, C-reactive protein.

Lab Results

  Result
Hematology Profile:

Leukocyte count (WBC)

  

9.3 x109/L
    Erythrocyte sedimentation rate 47 mm/hr
    Hemoglobin 11.7 g/dL
    Hematocrit 42%
    Platelet 288 x109/L
C-reactive protein (CRP) 20 mg/L
TSH 2.0 mIU/L
Coagulation Panel:

PT

  

14 s
    PTT 30 s
Chemistries:

Creatinine

  

1.2 g/dl
    BUN 20 g/dl

As she is drawing blood, the nurse notes that some of Ms. Armour’s responses seem confused, as she was talking about a “flying giraffe” and seemed somewhat drowsy.

Dr. Evans conducts a further neurological assessment, and finds failure of upwards gaze and internuclear opthalmoplegia. Some vertical nystagmus was noted. Power, tone, sensation and reflexes were all normal. Plantars were down-going bilaterally. There was not fine tremor.

Dr. Evans admits Ms. Armour and orders a CT of the head.

Stop here!

Identify important observations and generate hypotheses based on your observations. Using numbers or arrows (or some other system), link each hypothesis to the observation(s) which support that hypothesis. What assessments/interventions should occur next in Ms. Armour’s care?

Add to your list of learning issues.

The CT Tech completes Ms. Armour’s CT of the head.

Radiology Report

Examination: CT of the Head without contrast

History: Headache, confusion and drowsiness

Findings: A CT of the Head without contrast was obtained.  An area of low attenuation is identified within the left thalamus extending toward the midline and close to the third ventricle.

Impression: Acute infarct

 

Stop here!

Identify important observations and generate hypotheses based on your observations. Using numbers or arrows (or some other system), link each hypothesis to the observation(s) which support that hypothesis. What assessments/interventions should occur next in Ms. Armour’s care?

Add to your list of learning issues.

An MRI of the brain is performed on day 2 of admission.

Radiology Report

Examination: MRI of the brain

History: Acute infarct on CT

Findings: An MRI of the brain was obtained.  High signal changes in the left thalamus on T2-weighted and fluid attenuated inversion recovery (FLAIR) axial images are noted. The region demonstrates restricted diffusion on diffusion-weighted imaging (DWI) and low calculated apparent diffusion coefficients (ADC). The cerebral venous sinuses are patent.

Impression: Acute infarct

 

Stop here!  This is the end of the case. Complete your list of important observations. Clarify your hypothesis list, adding and removing hypotheses on the basis of observations from the case. Link each hypothesis to the observation(s) which support that hypothesis. Finalize your list of learning issues. Determine the most important learning issues to your team. Assign learning issues and create focused clinical questions that address those learning issues.

Media Attributions

  • CT Head
  • MR Head

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Evidence-Based Practice for Clinical and Diagnostic Professionals Copyright © 2023 by Carla M. Allen is licensed under a Creative Commons Attribution-NoDerivatives 4.0 International License, except where otherwise noted.

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