Soap Note: Laboratory test and results
Diagnostics
Head CT Scan – which is impending in accompaniment of angiography will be useful in the visualization of the brain tissues and the blood vessel structures(Turner, 2017).This can be used to trace bleeding site in case of bleeding or even mass in case of a brain tumor and also show the extent of the damage.
Urea, electrolytes and creatinine levels– sodium at 145, potassium at 4.1mg/dl, chloride- 104, CO2-25, glucose- 127, Blood urea Nitrogen- 17, Creatinine- 0.69, Calcium- 9.0, albumin-4.2.
Liver function tests– AST 12, ALT 10, ALK 89 and total bilirubin-0.3
Full hemogram– WBC 5.2, hemoglobin 11.3, hematocrit 34.5, platelet 256.
Complete blood count is used to monitor the platelet and hematocrit levels which are elevated in case of vessel injury (Walton et al., 2017).
Special tests
Magnetic Resonance Imaging(MRI)–to be done following Computed Tomography to give finer review and details of the brain, brain vessels tissues and structures(Schaafsma, Mikulis, & Mandell, 2016). It can also reveal the state of the nerve structures.
Cerebral Angiography— the test can be used to evaluate the structure of the blood vessels supplying the brain tissues (Mohan, Agarwal&Pukenas, 2016). In case of an aneurysm caused by a brain tumor and in case of leakage, it can be able to identify.
Diagnosis
Intracranial hemorrhage-– this can be a medical emergency. In this case, there is extravasation of blood into the surrounding brain tissues which can cause damage to the brain and adjacent structures. This can lead to an increased intracranial pressure generally above 15mmHg pressing on the cranial nerves (Zoerle et al., 2015). The exertion of force on the floor of the fourth ventricle triggers the vagus nerve making one experience nausea feeling, emesis or vomiting and even dry heaves in case one has not fed. The pressure exerted on the Vestibulocochlear can lead to one having dizziness and loss of balance. Likewise, with this patient, she complains of nausea, vomiting, dry heaves and spinning.
Brain tumor– this can be benign or cancerous. It can also be primary in that it starts with the brain or from other parts of the body as in the secondary tumor. The type of the brain tumor depends on the area of the brain affected (Nakajima et al., 2015). The patient may present with headaches that become more frequent and severe, unexplained nausea and vomiting, a problem in normal vision, gradual loss of sensation and movement of the extremities, hearing loss, seizures and hearing problems.
Hypertension—high blood pressure can cause the blood vessels of the brain to burst increasing intracranial pressure(Schlunk & Greenberg, 2015). Hypertension can also reduce cardiac output hence limiting the amount of blood pumped to the body organs including the mind. This can make a person fell dizzy, nauseated and even vomit. Hypertensive crisis can be accompanied by a severe headache and chest pain which the patient does not have.
Migraine headache—a severe headache that usually lasts for a long period usually on one side of the head ((Lipton, & Silberstein, 2015)). It is accompanied with nausea, vomiting and being sensitive to light. Lightheadedness can be among the manifestations followed by dizziness and confusion (Lipton, & Silberstein, 2015).
Final Diagnosis
The final diagnosis is Intracranial Hemorrhage which primarily presents with the signs and symptoms similar to hers. In this case, the patient presented with nausea and vomiting, dizziness and dry heaves which are classical symptoms that come about with increased intracranial pressures as a result of bleeding. Other differential diagnoses such as brain tumors and migraine headaches that can lead to nausea and vomiting due to the impact on the nerves can be eliminated based on the fact that they are usually marked by a headache which is absent in this case. The computed tomography will ask to assist in providing more information concerning brain tissues and cells.
PLAN
Further testing
Electrocardiogram to be repeated due to its non-specificity. The non-specific electrocardiogram may be indicators of nonspecific ST segment, Q- wave or T –wave findings.
Computed Tomography- to be facilitated for the results to be obtained today
Medication
Put on meclizine 12.5mg three times in a day.
20% Mannitol 1.5gm/ kg body weight intravenous infusion over 30-60 minutes. According to (Dash, 2016) mannitol is conservative management for increased intracranial pressure.
Further plan
Ensure close monitoring of the patient for danger signs. In case the patient’s condition worsens by presenting within additional symptoms including; a headache, tingling sensation, numbness, headache and persisted nausea and vomiting, proceed to the emergency room.
Education
The health education revolves around the condition the patient is presenting with and the lifestyle the patient ought to report any new symptoms such as a headache and disturbed and exacerbation of present manifestations. The health education also entails compliance with the medication as well as the follow-up clinic.
Referrals or consultations
The patient to seek further review by a psychiatrist due to the complaints and symptoms of anxiety as well as depression. Through the review, the management and medication for the condition can be prescribed and administered.
Reflection notes
From this experience, I have been able to interact with the patient by developing a therapeutic relationship which has been useful throughout the assessment. I was able to learn various ways of extracting information from the patients especially in the history taking sessions. This process allowed me to use multiple forms of asking questions and interrogating the patient to get relevant and useful information that would assist in her care. Besides the experience in history taking, I was able to use various tools, techniques, and guidelines to conduct the physical examination thus eliciting objective information from the patient to enhance the care. Throughout interaction with the patient, I was also able to employ various virtues of nursing such as empathy to make the patient comfortable in illustrating her needs thus the openness.
References
Dash, P. K. (2016). Biomarkers Prognostic for Elevated Intracranial Pressure. The University
of Texas Health Science Center at Houston Houston United States.
Heit, J. J., Pastena, G. T., Nogueira, R. G., Yoo, A. J., Leslie-Mazwi, T. M., Hirsch, J. A., &
Rabinov, J. D. (2016). Cerebral angiography for evaluation of patients with CT
angiogram-negative subarachnoid hemorrhage: an 11-year experience. American
Journal of Neuroradiology, 37(2), 297-304.
Mohan, S., Agarwal, M., & Pukenas, B. (2016). Computed tomography angiography of the
neurovascular circulation. Radiologic Clinics, 54(1), 147-162.
Lipton, R. B., & Silberstein, S. D. (2015). Episodic and chronic migraine headache: breaking
down barriers to optimal treatment and prevention. Headache: The Journal of Head and
Face Pain, 55(S2), 103-122.
Nakajima, R., Nakada, M., Miyashita, K., Kinoshita, M., Okita, H., Yahata, T., & Hayashi, Y.
(2015). Intraoperative Motor Symptoms during Brain Tumor Resection in the
Supplementary Motor Area (SMA) without Positive Mapping during Awake
Surgery. Neurologia medico-chirurgica, 55(5), 442-450.
Schaafsma, J. D., Mikulis, D. J., & Mandell, D. M. (2016). Intracranial vessel wall MRI: an emerging technique with a multitude of uses. Topics in Magnetic Resonance
Imaging, 25(2), 41-47.
Schlunk, F., & Greenberg, S. M. (2015). The pathophysiology of intracerebral hemorrhage
formation and expansion. Translational stroke research, 6(4), 257-263.
Turner, R. D., Vargas, J., Turk, A. S., Chaudry, M. I., & Spiotta, A. M. (2015). Novel device and
technique for minimally invasive intracerebral hematoma evacuation in the same setting
of a ruptured intracranial aneurysm: combined treatment in the
neurointerventional angiography suite. Operative Neurosurgery, 11(1), 43-51.
Walton, B. L., Lehmann, M., Skorczewski, T., Holle, L. A., Beckman, J. D., Cribb, J. A., … &
Pawlinski, R. (2017). Elevated hematocrit enhances platelet accumulation following
vascular injury. Blood, 129(18), 2537-2546.
Zoerle, T., Lombardo, A., Colombo, A., Longhi, L., Zanier, E. R., Rampini, P., & Stocchetti, N.
(2015). Intracranial pressure after subarachnoid hemorrhage. Critical care
medicine, 43(1), 168-176.
Soap Note: Laboratory test and results
