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Scenario 1: 74-year-old Male with a History of Hypertension and Smoking

Scenario 1: 74-year-old Male with a History of Hypertension and Smoking

The provided case study is about a 74-year-old man who is brought to the emergency department with history of difficulty in speaking, weakness in the left hand, and drooling from the left side of his mouth. The patient has a history of hypertension and smoking. The above symptoms progressed for 10 minutes making it difficult for him to stand or raise his arm. Baseline data revealed elevated blood pressure with normal oxygen saturation, mild drift on the left leg, and left arm being unable to resist gravity. Therefore, this essay examines the neurological and musculoskeletal processes that would contribute to the symptoms that the patient presented with to the hospital. It also examines ethnic or racial variables that might affect physiological functioning and their interaction to cause the problem.

The patient in the above case is likely to be diagnosed with transient ischemic attack or ischemic stroke. Ischemic stroke has neurological basis that caused the symptoms the client presented with the hospital. As shown in the case, the patient is a smoker and hypertensive. Smoking is a risk factor for hypertension and ischemic stroke. It activates a series of cascades that leads to stroke. It causes injury to the artery walls, which leads to monocyte adhesion, insinuation, and acvtiation of T-lymphocyte immune mechanism. These processes lead to the release of reactive oxygen radicals that form foam cells, enhance cytotoxic activity, and inhibit macrophase egress from plagues. These processes result in migration and proliferation of inflammatory cells such as eicosanoids and cytokines into the cell intima. The proliferation causes platelet aggregation and adhesion, thrombus formation, and cerebral atherombosis that cause occlusion of blood flow to the brain (Lee, 2017).

The occlusion of the blood flow causes cerebral ischemia that cause neurophysiology, biochemical, and hemodynamic alterations. The most significant neurophysiology changes include the release of excitatory neurotransmitters including aspartate and glutamate through excitotocity process. The neurotransmitters cause excessive calcium ion release and potassium ion efflux. Calcium influx increases the release of destructive enzymes such as lipases, proteases, and endonucleases that stimulate additional efflux of cytokines causing further inflammation of the cerebrum (Lee, 2017). Consequently, energy loss in the brain causes the symptoms the client presented with such as slurred speech and left-sided drooling due to mid-brain involvement.

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Musculoskeletal processes also contributed to the client’s problem. Often, patients with stroke have bilateral or cortical lesions that cause aphasia and hemipheligia. Cerebral edema occludes the connections in the corpus callosum, hindering the motor execution of speech through execution to supplementary motor area of the brain. This can result in stuttering. Lesions in the anterior cerebral artery due to ischemia increase the risk of contralateral lower limb weakness and possibly hemiplegia and paraplegia. Hemiplegia can also arise from cortical lesions caused by ischemia that affect the non-dominant hemisphere. Medullary infarctions can result in swallowing difficulty and bronchospasm. Therefore, these processes account for the symptoms of the patient.

There exists some influence of ethnic/racial variables on the physiological response in patients with stroke. For example, a research conducted by Johnson et al., (2017) revealed that blacks with stroke were highly at a risk of severe neurocognitive impairment when compared to whites suffering from the disease. Other variables that included low health literacy, decreased confidence, and variation in insurance type worsened the outcomes of the disease in blacks than in whites. There is also a difference in population attributable risk (PAR) across ethnicities (O’Donnell et al., 2016). The risk of transient ischemic attack was found to be significantly higher in African and black Caribbean when compared to the whites. Therefore, these factors interplay to increase one’s vulnerability to transient ischemic attack. For example, black ethnicity and smoking is associated with enhanced risk of developing stroke when compared to white ethnicity.

Scenario 1: 74-year-old Male with a History of Hypertension and Smoking


Johnson, N. X., Marquine, M. J., Flores, I., Umlauf, A., Baum, C. M., Wong, A. W., … & Heaton, R. K. (2017). Racial differences in neurocognitive outcomes post-stroke: the impact of healthcare variables. Journal of the International Neuropsychological Society23(8), 640-652.

Lee, S. H. (Ed.). (2017). Stroke Revisited: Diagnosis and Treatment of Ischemic Stroke. Springer.

O’Donnell, M. J., Chin, S. L., Rangarajan, S., Xavier, D., Liu, L., Zhang, H., … & Lopez-Jaramillo, P. (2016). Global and regional effects of potentially modifiable risk factors associated with acute stroke in 32 countries (INTERSTROKE): a case-control study. The lancet388(10046), 761-775.

Scenario 1: 74-year-old male with a history of hypertension and smoking, is having dinner with his wife when he develops sudden onset of difficulty speaking, with drooling from the left side of his mouth, and weakness in his left hand. His wife asks him if he is all right and the patient denies any difficulty. His symptoms progress over the next 10 minutes until he cannot lift his arm and has trouble standing. The patient continues to deny any problems. The wife sits the man in a chair and calls 911. The EMS squad arrives within 5 minutes. Upon arrival in the ED, patient‘s blood pressure was 178/94, pulse 78 and regular, PaO2 97% on room air. Neuro exam – Cranial nerves- Mild left facial droop. Motor- Right arm and leg extremity with 5/5 strength. Left arm cannot resist gravity, left leg with mild drift. Sensation intact. Neglect- Mild neglect to left side of body. Language- Expressive and receptive language intact.

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