Neurological Case Study

1. Define stroke. Describe the differences between ischemic and hemorrhagic stroke.

Stroke: It is defined as failure of the heart to meet the body demands of adequate circulation for its metabolizing tissues.

Ischemia stroke arises when the blood flow to the tissue is so low that adequate oxygen is not delivered to them despite a normal arterial pO2 and hemoglobin concentration.

Hemorrhagic stroke is the loss of more than 30-40% blood volume which results in a fall in blood pressure and gross hypoperfusion of the tissues leading to hemorrhagic stroke

 What are the factors that place an individual at risk for stroke?

Infections especially pulmonary are known to precipitate stroke putting extra load on the heart Severe anemia Pulmonary embolism Pregnancy in a women with already existing valvular heart disease Myocarditis Bacterial endocarditis Hypertension Massive acute myocardial infarction Rapid and excessive fluid loss/blood transfusion Physical and emotional stress Thyrotoxicosis 3. What specific signs and symptoms that are noted in the patient’s exam and history that are consistent with her diagnosis?

·        History of hypertension

·        Weakness on the right side involving the right arm and leg

·        Dysarthria and tongue deviation

·        The patients age

·        Present dizziness

Provisional diagnosis: Transient ishemic attack with supranuclear cranial (12th nerve) palsy.

4. Which symptoms from above may place the patient at nutritional risk? Explain your rationale.

The patient is hypertensive hence the diet and salt intake should be monitered, diet of low carbohydrate and low fat is advised. The patient has difficulty in swallowing, has esophageal dysphagia hence liquid to semi solid food is advised.

5. Define dysphagia.

Dysphagia is difficulty in swallowing and its cause may be either a local pathology or its part of a generalized systemic disease. Very often the patient points to the exact position of obstruction in the esophagus.

6. What is the primary nutrition implication of dysphagia?

As the patient would be having difficulty is swallowing, texture modified food is advised or else she may face malnutritional problems. Heavy doses of iron is recommended, hence diet containing iron like green leafy vegetables is advised. The etiological factors are to be considered and treated accordingly. Texture modified food, soft food along with nutrient supplements is recommended.

7. It is determined that the patient’s dysphagia is centered in the esophageal transit phase, and she has reduced esophageal peristalsis. Which dysphagia diet level is appropriate to try with the patient?

Considering that the patient has esophageal dysphagia, diet level 2 is advised

Dysphagia diet level 2:

This is a step up from the pureed diet. Some chewing ability is required. The level 2 diet is for people with mild to moderate swallowing difficulty. This diet consists of foods that are moist, soft and easily formed into a bolus (soft wad of food). Avoid foods that are difficult to chew, dry and coarse Meats should be ground or minced and should be keep moist with sauces and gravies.

8. Select two high-priority nutrition problems for the patient. For each one establish a goal (based on signs and symptoms) and an appropriate intervention (based on etiology).

·        Esophageal dysphagia occurs when food/liquid stops in the esophagus. This happens most often because of consistent stomach acid refluxing (backing up) into the esophagus. Over time, the reflux causes inflammation and a narrowing (stricture) of the esophagus

   Management for this would be to stick to smooth/liquid to semi solid food, as mentioned above.

·        The patient is hypertensive hence few things ought to be kept in mind:

o   Weight reduction especially in obese must be enforced. For weight control, diet be advised

o   Minimum quantity of food with regular meals. As the patient has hyperlipidemia, the calories must be in check and restricted fatty food is advised.

o   Salt in the diet be restricted

o   Regular exercise is advised. Regular walk would be helpful

o   Patient must have adequate periods of rest amd sleep. Tension and stress be avoided

o   Excessive use of alcohol and its related products must be restricted

9. To maintain or attain normal nutrition status while reducing the danger of aspiration and choking, texture (of foods) and viscosity (of fluids) are personalized for a patient with dysphagia. In the following table describe each term used to define the characteristics of food and give an example.

Term Definition Example Consistency Degree of density and firmness Beating the mixture to a butter consistency (butter has smooth consistency) Texture The appearance and feel of the surface A rough or graining surface;

Texture of cooked fish Viscosity The property of holding together and retaining its shape The property of having viscosity like a jelly 10. Using the previous 24 hour recall make suggestions for consistency changes or food substitutions if needed.

Foods are puréed to a smooth, mashed potato-like consistency. If necessary, the puréed foods can keep their shape with the addition of a thickening agent. Meat is puréed to a smooth pasty consistency. Hot broth or hot gravy may be added to the puréed meat, approximately 1 oz of liquid per 3 oz serving of meat. If any food does not purée into a smooth consistency, it may make eating or swallowing more difficult.

Sample Menu Breakfast Lunch Dinner orange juice 1/2 cup cream of wheat 1/2 cup scrambled eggs with cheese 1/2 cup decaffeinated tea 1 cup whole milk 1 cup non-dairy creamer 2 Tbsp margarine 1 tsp sugar 2 tsp pineapple juice 1/2 cup puréed beef 3 oz gravy 2 Tbsp mashed potatoes 1/2 cup puréed fresh broccoli 1/2 cup apple sauce 1/2 cup decaffeinated coffee 1 cup non-dairy creamer 2 Tbsp margarine 1 tsp sugar 1 tsp puréed turkey barley soup 3/4 cup puréed Hawaiian chicken 3 oz mashed potatoes 1/2 cup puréed spinach 1/2 cup frozen yogurt 1/2 cup decaffeinated tea 1 cup non-dairy creamer 2 Tbsp margarine 1 tsp sugar 1 tsp

11. Describe R.B.’s potential nutritional problems upon discharge. What recommendations would you make to her husband to prevent each problem you identified? How would you monitor her

·         Being hypertensive the patients diet should be monitored, preferable low fat diet with restricted salt is advised.

·        For esophageal dysphagia management would be to stick to smooth and liquid food as mentioned before.

·        Adequate rest should be taken.

·        Regular check up with her physician.

  And all the above mentioned conditions are to be taken into consideration and are followed.

References:

Braunwald E: heart disease 5th edition W. B. Saunders company, Philadelphia, 1997 Khosla Medicine for dental students 1st edition, 2007, India