Diagnostic Case Discussion: Subarachnoid Hemorrhage Brief Patient

Diagnostic Case Discussion: Subarachnoid Hemorrhage Brief Patient History A 64 year old female presented to the emergency department with a chief complaint of severe headache which she rated at a 6 on a 1 – 10 pain scale. She stated that she had “never had a headache like this before”. The headache had a 1-day onset with no other symptoms and Acetaminophen achieved mild relief. Clinical Assessment The patient scored 15/15 on the Glascow Coma Scale, was moving all extremities spontaneously with full strength, pupils were equal and reactive to light. BP of 138/69, regular pulse rate of 83 beats/minute, respirations of 20 breaths/minute with oxygen saturation of 96% on room air. Her temperature was 37.3C. She denied complaints of neck stiffness, nausea or vomiting, but was experiencing some photophobia. Her past medical history included mild hypertension, migraine headaches and smoked a half pack cigarettes a day for 40 years. She lived alone and could normally manage her duties without restriction. Diagnostic Information A non-contrast CT scan of the head showed an 11 x 13 mm nodule in the left posterior communicating artery which was indicative of a large aneurysm. There was no evidence of intraparenchymal blood. Medical Diagnosis Subarachnoid Hemorrhage Questions 1. What is the clinical definition for the diagnosis? 2. What are the factors which can cause this clinical condition? 3. What are your patient’s contributing factors (history and clinical data)? 4. What additional clinical data would you like to see? 5. What signs and symptoms do you expect of this physical presentation? Which ones are present in your patient? a. Neurological b. Respiratory c. Cardiovascular d. Skin e. Gastro-intestinal f. Genito-urinary 6. What major outcomes do you expect to achieve for this patient? 7. What problems or risks must be managed to achieve these outcomes? 8. What interventions must be initiated to monitor, prevent, manage, or eliminate the problems and risks identified? a. What types of orders would you expect to see? i. Monitoring ii. Classification of meds (ie, anti-infectives, anti-emetics, etc) iii. Type of IV fluid preferred / rate? iv. Type of oxygen therapy v. Additional diagnostic studies vi. Treatments 9. What would be your “worst case” complication for this patient? a. What are the warning signs and symptoms that your patient might be reaching this level? (include clinical and diagnostic findings). 10. What possible learning needs would you anticipate for this patient? 11. What cultural and age-related factors might have a bearing on the patient’s plan of care?

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