Course Case Studies

Pathophysiology: The Central Nervous System

Course #38921 - $90 -

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    • Review your Transcript to view and print your Certificate of Completion. Your date of completion will be the date (Pacific Time) the course was electronically submitted for credit, with no exceptions. Partial credit is not available.
Learning Tools - Case Studies


Patient A, 85 years of age, wakes in the morning to paralysis on his whole right side and no sensation in his arm or leg. He tries to get up with help from his wife but cannot. Mrs. A calls their physician and describes the situation. The physician instructs her to call 911 to have her husband taken to the hospital by ambulance, where he will meet them. Patient A protests but ultimately cooperates with emergency medical services when they arrive. He is quickly evaluated upon arrival in the emergency department and is admitted to the critical care unit (CCU).

Past Medical History

Patient A lives with his wife in their own home in a lower-middle class neighborhood. They have four sons who are living in different parts of the country. Until five years ago, Patient A had worked as a house painter.

Patient A's wife provides the patient's medical history. Patient A has not had any significant illness until two years ago, when he began to develop bilateral cataracts. Since then, he has consumed increasing amounts of alcohol as the encroaching cataracts impaired his ability to pursue his hobby of building ship models. Six months ago, the cataracts were successfully removed and lenses implanted. Since then, Patient A's alcohol consumption has decreased and he has resumed work on his models.

Mrs. A reports no knowledge of high blood pressure, heart disease, lung disease, kidney disease, cancer, or any other serious medical illness in the patient. He has no history of surgery or serious injuries during their 65 years of marriage.

Assessment and Diagnosis

Upon admittance to the CCU, a full physical exam is conducted (Table 1). Several laboratory tests are ordered, with the following results:

  • Complete blood count with differential: Within normal limits

  • Serum electrolyte levels: Within normal limits

  • Serum glucose level: Mildly elevated


General appearance
Semiconscious and aphasic. Made no attempt to respond verbally to questions.
Height: 5 feet 9 inches (175 cm)
Weight: 163 pounds (74 kg)
Head and eyes
Face flushed
Pupils equal, round, reactive to light, accommodation
Corneal reflexes present
Unable to test extraocular muscle function
Nasal passage clear, with septum deviated to the left
Edentulous, full dentures not in place, gums without lesions
Tongue deviated to the left when protruded spontaneously
Facial drooping on left
Tympanic membranes intact and clear
No history of impaired hearing
Symmetrical excursion while lying in bed
Lungs clear to auscultation and percussion
Breath sounds diminished in the bases
Bowel sounds present in all quadrants
Soft and without masses or organomegaly on palpation
ExtremitiesFlaccid right arm and leg
Genitourinary systemNormal adult male with smooth, enlarged prostate gland
Neurologic status
Spontaneous respirations with regular variation in depth and rate
Deep tendon reflexes in arms and femorals: 2+
Deep tendon reflexes in popliteals, posterior tibials, and dorsalis pedis: 1+
Spontaneous movement and active response to pain in left arm and leg
Grimace but no movement with pain in right extremities
Cardiovascular system
Heart sounds consisted of normal S1, S2, and S3
Soft systolic ejection murmur heard at second intercostal space to right of sternum
Vital Signs
Blood pressure200/110 mm Hg
Temperature100° F
Heart rate86 bpm and regular
Respiratory rate
22 breaths per minute and stertorous
Oxygen mask in place with flow at 8 L/min

Based on the results of the assessment, Patient A is diagnosed with:

  • CVA (thrombosis or aneurysm of left middle cerebral artery), with right hemiparalysis and hemiparesis and questionable aphasia

  • Benign prostatic hypertrophy


When Patient A is admitted to the CCU, the nurse orients him and his wife to the physical layout and pertinent policies of the unit. The nurse also completes an initial physical assessment while carrying out the medical and nursing orders for supportive management. Nursing actions include:

  • Continue oxygen by mask at 8 L/min and obtain arterial blood gas sample.

  • Take vital signs every 15 minutes until stable, then every 30 minutes for two hours, then increasing interval until every four hours.

  • Complete neurologic checks every hour.

  • Insert IV devices and administer dextrose 5% in water (D5W) at a rate of 100 mL/hour.

  • Insert 16F indwelling urinary catheter connected to a urinometer.

  • Monitor and record intake and output every hour.

  • Suction oropharynx to stimulate coughing and remove secretions.

  • Frequent oral care, including Patient A's usual denture care routine.

  • Repositioning every two hours, with body kept in functional alignment.

  • Skin care and some passive range of motion with each turning so all joints are exercised every eight hours.

  • Administer ordered medications:

    • Acetylsalicylic acid (aspirin): 650 mg every six hours

    • Sodium nitroprusside (Nipride) infusion: As needed to maintain systolic arterial pressure between 170 and 180 mm Hg

Twelve hours after admission, the nurse assessing Patient A notes that his eyes are half open, with ptosis of the right eyelid, and eye movements occur when the nurse or his wife speaks his name. Patient A's right cheek is more flaccid than the left. His right arm and leg are limp with no muscle tone. There is some grasp strength in the patient's left hand, although he does not grasp on command. Patient A responds with grunts to painful stimuli but does not attempt to speak, follow commands, or answer questions.

Study Questions

  1. Outline a complete neurologic status assessment.

  2. How did the physician conclude that Patient A's CVA involved the left side cerebral artery?

  3. What signs and symptoms would alert the nursing staff to occlusion of the left anterior or posterior cerebral artery?

  4. Why did the physician order sodium nitroprusside to keep Patient A's systolic arterial pressure between 170 and 180 mm Hg?

  5. What nursing diagnoses or nursing problems and outcomes assume priority in the acute care period of a CVA?

  6. What other disciplines would be expected to assist in rehabilitation of a patient with a CVA? When should disciplines such as physical and occupational therapy be expected to begin working with the patient?


Patient B is a white woman, 67 years of age, who felt well until approximately one week ago, when she developed an upper respiratory tract infection. She has improved slowly, but during the past 48 hours she has developed a more severe cough with significant production of rust-colored sputum, fever with occasional shaking chills, and muscle aches. Patient B arrives at the hospital emergency department. She is transported by her husband, who was concerned when the patient woke in the morning mildly confused and complaining of a severe headache.

At the hospital, Patient B informs the physician (with some difficulty concentrating) that she has had a "bad cold" for about a week. She explains that her neck feels stiff, sore, and extremely painful when she tilts her head forward and bright lights hurt her eyes. She also tells the physician that she has had no skin rashes, nausea, or vomiting but has had some severe chills. She does not recall any of her recent contacts being ill, and she denies any difficulty breathing or chest pain.

Past Medical History

Patient B denies any past history of head trauma, sinus infection, immunodeficiency disorders, or medications that cause immunosuppression. She has smoked a half-pack of cigarettes each day for the last 45 years, was diagnosed with emphysema five years ago, and had several severe episodes of chronic bronchitis and one episode of pneumonia in the past two years. Her emphysema is being managed with ipratropium bromide delivered with a metered-dose inhaler (two to four puffs every six hours). She has never suffered from episodes of angina or symptoms of heart failure. She has an allergy to peanuts but not to any medications. She is taking no medications other than ipratropium and combined estrogen plus progestogen therapy for menopausal symptoms. The patient was vaccinated for influenza six months previously and pneumococcus when she turned 65 years of age.

Assessment and Diagnosis

Upon admittance to the CCU, a full physical exam is conducted (Table 2). A blood chemistry panel, chest x-rays, and lumbar puncture are ordered. Chest x-ray finds shadows on the right middle and lower lobe consistent with pneumonia; the left lung is clear but hyperinflated. Several laboratory tests are ordered, with the following results:

  • Hematocrit: 41%

  • Hemoglobin: 14.8 g/dL

  • Red blood cells: 5.2 million/mL

  • White blood cells: 14,000/mL (90% neutrophils)

  • Platelets: 280,000/mL

  • Sodium: 145 meq/L

  • Potassium: 5.0 meq/L

  • Chloride: 110 meq/L

  • Calcium: 9.3 mg/dL

  • Bicarbonate: 22 meq/L

  • Fasting blood glucose: 123 mg/dL

  • Blood urea nitrogen: 12 mg/dL

  • Creatinine: 1.0 mg/dL

  • CSF white blood cells: 1,100/mL (predominately neutrophils)

  • CSF protein: 1,254 mg/dL

  • CSF glucose: 40 mg/dL

  • CSF gram stain: Positive for encapsulated diplococci

  • CSF culture: Positive forStreptococcus pneumoniae

  • Sputum gram stain: Positive for diplococci


General appearance
Slight female in acute distress, with headache, intermittent chills, and constant coughing. Appears older than her stated age.
Height: 5 feet 0 inches (152.5 cm)
Weight: 97 pounds (44 kg)
Head and eyes
Normocephalic with no signs of head injury
Pupils equal at 3 mm, round and sluggishly reactive to light
Difficult to view fundi due to photophobia, but no papilledema observed
Nares slightly flared, purulent discharge visible
Pharynx red with purulent postnasal drainage
No tonsillar exudates
Mucous membranes moist
EarsWithin normal limits
Stiff and painful with flexion
Shows mild anterior cervical lymphadenopathy
Significant use of accessory muscles
Breath sounds markedly decreased in right middle and lower lobes
Crackles present at right posterior axillary line
Clear left lung, both upper and lower lobes
Flat, soft, non-distended, with no tenderness to palpation
Bowel sounds present in all four quadrants and within normal limits
No masses, bruits, or organomegaly
Peripheral pulses full and symmetric in all extremities
No cyanosis, rashes, or edema upon careful inspection
Mild clubbing
Genitourinary systemNormal adult female
Neurologic status
Oriented, but conversation is slightly confused
Level of consciousness assessed at 14 on Glasgow Coma Scale
Cranial nerves intact, including eye movements
Strength 5/5 and symmetric throughout
Deep tendon reflexes 2+ and symmetric
Gait steady
Positive Kernig and Brudzinski signs
Cardiovascular system
Distinct S1 and S2 with no murmurs or gallops
Regular rate and rhythm
Skin warm, moist, and pale
Vital Signs
Blood pressure160/74 mm Hg (right arm sitting)
Temperature101.5° F
Heart rate115 bpm and regular
Respiratory rate
24 breaths per minute and slightly labored
Oxygen mask in place with flow at 8 L/min

Based on the physical examination and results of diagnostic testing, a preliminary diagnosis of meningitis is made. Patient B is admitted to the hospital for treatment and continued observation.

Study Questions

  1. List clinical manifestations that strongly suggest that a patient has developed meningitis.

  2. Why is it appropriate for the physician to examine the patient for a head injury?

  3. Define papilledema and explain the significance of lack of papilledema in this patient.

  4. Explain the pathophysiology behind this patient's lymphadenopathy.

  5. Is the patient's rating on the Glasgow Coma Scale normal or abnormal?

  6. Based on all of the available test data, what is an appropriate neurologic diagnosis for Patient B?

  7. How did this patient's neurologic condition probably develop?

  8. Which type of white blood cell predominates in the blood and CSF of patients with acute bacterial meningitis?

  • Back to Course Home
  • Participation Instructions
    • Review the course material online or in print.
    • Complete the course evaluation.
    • Review your Transcript to view and print your Certificate of Completion. Your date of completion will be the date (Pacific Time) the course was electronically submitted for credit, with no exceptions. Partial credit is not available.