[sarettah]

Originally posted by Mary34D@Feb 19 2004, 02:26 PM
(still working on it...it's just a rough draft)


The patient was admitted into the emergency room after certain life threatening physical indications became perceptible to him while cooking at an outdoor barbecue. He was a fifty-nine year old man who was employed as a right-handed carpenter with a twelfth-grade education level. The patient had diabetic hypertensive, and also had a history of alcohol abuse. At the emergency room a CT scan was administered and a neuropsychological examination was conducted. These Computerized Tomography (CT) scans take cross-sectional x-ray images of selected parts of the body, wherefore, helping determine whether the stroke was ischemic or hemorrhagic in nature, as well as pinpoint its location. Then the neuropsychological examination was conducted to assess the patient’s motor, sensory-perceptual, language, memory, and conceptual abilities. The diabetes would be classified as diabetes II since it came about later in adulthood. The factors that lead the patient to the emergency were explained as a sudden onset of left-sided weakness and neglect, which remained even during the exam. Since the paresis was on the patient’s left side, and being right-handed, his carpentry hand remained relatively intact. He could recall this event, since his mental status was described as intact with minor exceptions such as short-term memory and rambling speech. Also, the examination of language yielded essentially normal results except for a mild articulatory problem. Recall of verbal material was normal but the recall of nonverbal material, such as geometric designs, was found to be exceptionally poor. Also, nonverbal reasoning skills were found to be substantially less intact than verbal skills. The sensory-perceptual exam found that he neglected both the visual and auditory stimuli to his left side. He also showed substantial difficulties with rapid visual scanning. He had substantial difficulties with complex visual, perceptual, and constructional tasks. General intellectual functioning was found to be in the low-average range.
Given all the information stated above, this patient suffered a CVA in the posterior cerebral artery. This CVA was also an Ischemic, which was caused by a blood clot or a narrowing of posterior cerebral artery, leading to the brain. Atherosclerosis caused the plaque to roughen the inside of an artery and the vessel began to narrow, the flow of oxygen and nutrients to the brain became disrupted. Exactly where in the artery the blockage occurs determines which part of the brain will be affected. Being that the patient was a diabetic, one can presume that it was called a diabetic related stroke because diabetes is a major risk factor for stroke, however, his stroke could have also occurred in the context of severely elevated blood sugar, hyperosmolar diabetic coma. “Diabetes Mellitus is can be a cause for hemiparesis, in this case right hemiparesis, where symptoms include sudden unilateral extremity weakness, loss of function and reflects spinal cord or higher involvement.”
Moreover, the problems noted by the neuropsychological examination can conclude that a posterior cerebral artery CVA occurred. This can be explain since the part of the brain that was affected was where the oxygen was blocked. The patient suffered visual changes such as cortical blindness, lack of depth perception, failure to see objects not centered in the visual field, and homonymous hemianopia. Mr. Fix-It had neglect in the left visual and auditory stimuli to his left side concluding the right parietal area was therefore affected causing him to lose the left half of the visual field from both eyes. This caused the difficulties in geometric design and nonverbal material. The CVA was also caused hemiparesis of the right hemisphere. The posterior cerebral artery CVA would also cause memory loss, which was confirmed with the patient’s loss of short-term memory. Because this type of CVA lesions result in motor reflexes in area four, constructional apraxia caused Mr. Fix-It to have difficulty with willed movement. This also including rapid visual scanning and rambling speech. An intension tremor could evolve if there was damage to the thalamic or subthalamic nuclei. If cerebral peduncle involvement was involved, cranial nerve III, the oculomotor nerve has been affected. These areas affected were all due to the posterior cerebral artery CVA.
Later on, after several months, the patient became chronically depressed. Due to his now inability to function as a carpenter and other social, now, inhibitions, could be the reason for this. The association between depression and stroke has long been recognized for its negative impact on an individual's rehabilitation, family relationships, and quality of life.
Stroke has long been recognized as a cause of depression, and in patients with strokes, depression afterward is really the rule, not the exception. Part of this relates to obvious so-called situational depression or "adjustment disorder" type depression, where one is depressed in response to some negative event in his or her life, such as the death of a loved one, for instance, or in this case, the sudden disability caused by the stroke itself. The incidence and extent of depression in stroke go well beyond this simple connection, however. Most doctors who have studied this phenomenon believe that the actual destruction of the brain tissue caused by the stroke has adverse effect on all the other parts of the brain that previously connected via cross fibers to the damaged area, including the parts of the brain that control and regulate mood. Another area of brain function also frequently affected by strokes that most people are too embarrassed to ask about and most doctors fail to discuss is sexual function. Often after a stroke, even if it is only a small one, there is a loss of libido.

Of the 600,000 Americans who experience a first or recurrent stroke each year, an estimated 10-27 percent experience major depression. An additional 15-40 percent experience depressive symptomatology (not major depression) within two months following the stroke….Among the factors that effect the likelihood and severity of depression following a stroke are the location of the brain lesion, previous or family history of depression, and pre-stroke social functioning.

After a stroke, Mr. Fix-it should seek treatment to rebuild lost functions and coop with depression and other side effects. Appropriate diagnosis and treatment of depression can shorten the rehabilitation process and lead to more rapid recovery and resumption of routine. It can also save health care costs.
Depression after stroke should be treated aggressively just as any other type of depression, especially in those patients with significant residual disability, since a lack of motivation or pleasure (also known as anhedonia) will often interfere with an otherwise smooth course of gradual recovery, producing a psychologically based setback in NEUROLOGIC functioning…….think the most important thing for you to realize, however, is that like regular depression, stroke-related depression is generally treatable with antidepressants.

The mean duration of major depression in stroke patients has been shown to be just under a year. Among the factors that effect the likelihood and severity of depression following a stroke are the location of the brain lesion, previous or family history of depression, and pre-stroke social functioning. Post-stroke patients who are also depressed, particularly those with major depressive disorder, are less compliant with rehabilitation, more irritable and demanding, and may experience personality change.
Another factor he must take into consideration is the recurrence of CVAs in the future. For this he must see treatment for diabetic hypertension. Wherefore, he must maintain a proper diet, exercise, and control high blood pressure and sugar. Also certain medication can assist in this.
The mainstay of therapy is to prevent the blood from clotting by using Asprin, not as a painkiller but because it this the blood. Most Doctors recommend a dose of 325mg so four tablets sounds like a lot, and may cause stomach upset. If Asprin is
not strong enough a drug called Ticlid is used. It sounds like you are on the right track although a second opinion to fine tune therapy might be a good idea.
With this in mind he might be able to recover.
Recovery in this situation may be expected to fall within the general
principles of recovery for any stroke, 80% of the recovery will occur
within the first 3 months and can be expected to continue up to six
months after the event, in some cases very small increments of improvement
may be noted after six months.

Just to record that she posted this so she can't pull it.