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Physical Assessment: Demographic Data

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Question:

Write about the Physical Assessment for Demographic Data.

 

Answer:

Introduction

This is a case study of Katie McConnell, a 23-year-old lady presenting with a subdural hematoma due to mild traumatic injuries to the brain after a car accident.

Demographic data on Subdural Hematoma

A Subdural hematoma is not a usual complaint about the age group which Katie McConnell belongs. Older patients with trauma tend to have an acute subdural hematoma (Vollmer, Torner, Jane, Sadovnic, Charlebois, Eisenberg & Marshall, 2001). Studies show that the average age of patients with trauma but no acute subdural hematoma is around twenty-six years of age. However, the average age of patients who have subdural hematoma is around forty years. Therefore in our case study, that was an infrequent incident since the patient is only twenty-three years. A Subdural hematoma is commonly associated with old age because the older population has a substantial atrophy of the brain since it allows a shear force (Davis, & Richardson, 2015). A Subdural hematoma is not a usual complaint about women. Men are normally more affected as compared to women.

 

Clinical Presentation

The normal range of heart rate is between 60bpm and 100bpm. The normal blood pressure range from 120/80 to 140/90. Katie presents with increased heart rate of 87bpm and increased blood pressure 142/78 due to the rise in the intracranial pressure. The average oxygen saturation of blood levels is between 94% and 99%.  The standard respiratory frequency for a healthy individual is between 12 to 20 breaths per minutes. Katie had SpO2 OF 96% and 13 breaths per minute which show that she might have had only a mild respiratory distress. Glasgow coma scale is a neurological scale that is used to record the conscious level of a patient (Teasdale, Maas, Lecky, Manley, Stocchetti & Murray, 2014). The score is between 3 and 14. A score of about 3 points shows deep unconsciousness while a score of 14 shows full consciousness. Katie has a Glasgow Coma Score of 14 which indicates that she is fully conscious. In traumatic brain injury leading to subdural hematoma, the patient exhibit memory loss, and confusion. Katie presents with memory loss as she finds difficulties in recalling recent information unless prompted. Valuable information that is missing from the information and is useful is if gait and balance were okay. Individuals with traumatic brain injury and subdural hematoma tend to have an abnormal gait and loss of balance. There is no information on personality change which is common in similar cases.

 

Presenting Problem

The clinical presentation shows that the case of Katie is a mild traumatic brain injury. In instances where the patient has no history of previous head trauma, the subdural hematoma is usually considered as mild (Katz, Cohen & Alexander, 2015).). Therefore, Katie’s subdural hematoma is mild since from her medical history she has had only a painful ankle which she had acquired while playing basketball. There is a mild loss of consciousness, confusion, and disorientation. In such cases, the MRI and CT scans usually show normal results. Katie is expected to present with cognitive problems which include difficulty in thinking, attention deficit, frustration, headache, mood swings and memory problems. The patient also can exhibit fatigue, loss of balance, visual disturbances, depression, and seizures.

The assessment for mild traumatic brain injuries starts with checking of vital signs. The presence of tachycardia and hypertension should be assessed since these are associated with increased intracranial pressure (Friedman, 2014). A full neurological examination should be performed regarding pupil size, reactivity, and papilledema that also shows raised intracranial pressure (Karrar, Mansour & Bhansali, 2011). The presence of any external trauma to the head and other body parts should be determined. The various cognitive domains that are affected by mild traumatic brain injury needs to be assessed. Higher cognitive abilities, information processing, memory, and attention should be thoroughly examined (Carroll, Cassidy, Cancelliere, Côté, Hincapié, Kristman, & Hartvigsen, 2014). A standard assessment to determine the presenting complaint is through a detailed clinical interview. Katie should be asked about the highest level of education that she has attained. Then she should mention if there are any pre-existing learning difficulties. Katie’s medical and also psychological history should be given. Previous head injuries as early as childhood should be inquired.

 

Focused Health Assessment

Understanding the severity, nature and even the modalities of the cognitive complaint is evaluated using the neuropsychological assessment. Neuropsychological testing helps in diagnosis, treatment as well as the rehabilitation process (McCrea, Nelson & Guskiewicz, 2017). As noted above, the process starts with medical history taking and proceeds to tests. Various specific and focused investigations need to be carried out to determine the condition of Katie. These assessments are mostly imaging techniques. Since Katie has signs of raised intracranial pressure, urgent neuroimaging is needed. CT scan and MRI tests should also be performed to detect the extent of subdural hematoma (Yuh, Mukherjee, Lingsma, Yue, Ferguson, Gordon & Manley, 2013). Secondary injuries, for example, cervical spine structure should be radiologically surveyed. An electroencephalogram (EEG) should be performed on Katie to show the electrical activity of her brain. A person who does not have traumatic brain injury will show normal brain structure while viewed through MRI, CT scans, and X-ray. Katie will demonstrate the element of brain damage. The EEG values of Katie will show either beta activity or delta activity while those of an average person shows alpha activity.

 

Detailed Assessment

As noted above, various types of neurological tests are carried out during assessment in mild traumatic injury. These tests are grouped into two; those that evaluate the function of the brain and those that examine the structure of the brain after an injury.  The CT scans and MRI evaluate the structure of the brain. EEG and SPECT scans are used to determine the function of the brain.  The MRI and CT scan radiographically slices the brain into slabs. The MRI utilizes the magnetic fields while the CT scan uses x-ray (Levin & Diaz-Arrastia, 2015). These two tests can be used to show the extent of damage to Katie’s brain caused by trauma due to the car accident. The EEG will be used to monitor Katie’s brain electrical activity using various wires attached to her scalp. The healthy brain usually discharges signals at a frequency of between 8 and 13 cycles per second, which is referred to as alpha activity. Faster cycles are known as a beta activity, and slower cycles are known as delta activity. These findings should be recorded to determine the brain activity of Katie.

Skull x-rays to be taken. Headache history should be provided by Katie including a migraine, tension and substance withdrawal. One should also characterize visual complaints, evaluate ocular motor skills, describe pain complains that Katie presents. Dizziness, dyscoordination, and imbalance should be assessed by single-foot standing, star-march or Romberg. The cardiac status and also serum glucose level of Katie should be evaluated as these are a possible contributing factor to dizziness.  To ensure adequate medical assessment of Katie, overall fitness, conditioning, sensation, muscular strength, proprioception and range of motion should be evaluated.

Conclusion

Neurological emergencies are common in a clinical setting. Medical history taking is the most crucial process in the assessment and management of patients with traumatic brain injury that leads to the subdural hematoma. To be able to understand the presenting complaint, thorough interview and examination of the patient are paramount. After the physical examination, a focused health assessment is done followed by a more detailed evaluation to enable the health practitioner to make the differential diagnosis. The assessment should be systemic, and use of EEG, MRI and CT scans is paramount. Through the careful medical history taking and physical examination, we can formulate a differential diagnosis and even management plan for Katie.

 

References

Carroll, L. J., Cassidy, J. D., Cancelliere, C., Côté, P., Hincapié, C. A., Kristman, V. L., ... & Hartvigsen, J. (2014). Systematic review of the prognosis after mild traumatic brain injury in adults: cognitive, psychiatric, and mortality outcomes: results of the International Collaboration on Mild Traumatic Brain Injury Prognosis. Archives of physical medicine and rehabilitation, 95(3), S152-S173.

Davis, L. E., & Richardson, S. P. (2015). Traumatic Brain Injury and Subdural Hematoma. In Fundamentals of Neurologic Disease (pp. 225-233). Springer New York.

Friedman, D. I. (2014). Papilledema and idiopathic intracranial hypertension. CONTINUUM: Lifelong Learning in Neurology, 20(4, Neuro-ophthalmology), 857-876.

Karrar, E. E., Mansour, N., & Bhansali, A. (2011). Cranial and spinal trauma: Current concepts. Disease-a-Month, 57(10), 543-557.

Katz, D. I., Cohen, S. I., & Alexander, M. P. (2015). Mild traumatic brain injury. Handbook of clinical neurology, 127, 131-156.

Levin, H. S., & Diaz-Arrastia, R. R. (2015). Diagnosis, prognosis, and clinical management of mild traumatic brain injury. The Lancet Neurology, 14(5), 506-517.

McCrea, M. A., Nelson, L. D., & Guskiewicz, K. (2017). Diagnosis and Management of Acute Concussion. Physical Medicine and Rehabilitation Clinics of North America.

Teasdale, G., Maas, A., Lecky, F., Manley, G., Stocchetti, N., & Murray, G. (2014). The Glasgow Coma Scale at 40 years: standing the test of time. The Lancet Neurology, 13(8), 844-854.

Vollmer, D. G., Torner, J. C., Jane, J. A., Sadovnic, B., Charlebois, D., Eisenberg, H. M., ... & Marshall, L. F. (2001). Age and outcome following traumatic coma: why do older patients fare worse?. Special Supplements, 75(1S), S37-S49.

Yuh, E. L., Mukherjee, P., Lingsma, H. F., Yue, J. K., Ferguson, A. R., Gordon, W. A., ... & Manley, G. T. (2013). Magnetic resonance imaging improves 3?month outcome prediction in mild traumatic brain injury. Annals of neurology, 73(2), 224-235.

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