INTRODUCTION AND OVERVIEW OF AUTONOMIC DYSREFLEXIA
A 52 year old tetraplegic man, with history of Spinal Cord Injury (SCI) presented in the hospital with pounding headache, blurred vision, nausea and vomiting. During the examination, patient had multiple seizure episodes aswell. After further investigations patient got diagnosed as Autonomic Dysreflexia (AD). AD is a life threatening emergency normally associated with SCI in the thoracic vertebral level- T6 or above (Eldahan & Rabchevsky, 2017). Visceral and somatic stimuli like distented bowel or bladder can trigger AD by over stimulating the Autonomous Nervous System (ANS) (Eldahan & Rabchevsky, 2017). If untreated this can leads to hypertensive crisis, stroke, seizure or even death. This assignment explains the prompt assessment, diagnosis and underlying mechanism of the AD.
GENERAL APPEARANCE/PC/GENERAL HISTORY (Hx)
Mr. X, is a 52 year old New Zealand European man who is tetraplegic , brought in by ambulance from a hospital level residential care facility with severe headache. Mr. X appears alert and oriented, but also looks pallor, cold and calm to touch. When transfered from facility vital signs were Temperature (Temp): 36.2 degree Celsius, Heart Rate (HR): 56/minute, Respiratory Rate (RR): 18/minute, Blood pressure (BP): 182/100 mm of Hg. In ambulance patient had a seizure activity of less than 30 seconds. Observations done in ambulance showed significant increase in BP of 200/100 mm of Hg and a decrease in HR of 48/minute.
Reliability and source: Registered nurse from local residential facility referred Mr. X for further management and treatment via ambulance; patient`s brother present with patient, seems reliable.
CHIEF COMPLAINTS: Severe headache, blurred vision, nausea, vomiting, profuse sweating and nasal congestion
PRESENT ILLNESS: Mr. X complaints sudden onset of throbbing headache in the frontal region bilaterally for the last couple of hours. Residential care facility RN given some oral analgesics with very less effect. Normally patient have occasional frontal headache and that subside with analgesics and a good sleep, but now along with headache patient is having vision problems, nausea and vomiting.
Allergies: No known allergies.
Smoking: Quit nearly a year ago.
Alcohol & Drugs: Quit alcohol a year ago.No illicit drug usage.
Childhood illness: No rheumatic fever/scarlet fever/chickenpox /measles.
Medical History: Spinal Cord Injury(SCI) at T6 after a motorbike accident and tetraplegic since December 2017. Supra Pubic Catheter(SPC) present.
Type 2 Diabetes Mellitus(T2 DM).
Migrain headache since early early 30`s
Immunization :Had flu vaccination last year.
Screening: lipid profile and Hb A1C done 3 months ago.
Mr X got separated from his partner since he had motor bike accident.No kids.
Father, 85 year old gentleman having (T2 DM) along with recent decline in mobility staying in a residential care unit along with wife. She is 82 year old lady ,quiet well except for mild joint pains.
Brother 56 year old business man ,recently diagnosed with Coronary artery problems and T2 DM. His two boys healthy with no health issues.
No history of hereditary disease like cancer,anaemia or mental illness ,other than T2DM.
PERSONAL AND SOCIAL HISTORY:
Mr X, born and bought up in a remote village in Newzealand and moved to city for higher studies and job. Worked in overseas for few years ,not in past 3 years. He got married at age of 34 and got separated after 8 years ,his relationship with second wife also broken up after the motorbike accident. Patient denied anger or depression. Mr X has some friends ,but not happy to discuss any of his personal life with them .Patient now residing in a hospital level residential facility for 24/7 nursing care afer the SCI. Accident Claim and Compensation(ACC) is paying for Mr X`s treatment and cares.
Diet: normal diet with no food allergies
Excersise: carers give regular passive and stretching excersises .
DIAGNOSTIC CONSIDERATIONS LINKED TO APPEARANCE /PC/Hx
Considering Mr X`s general history and appearance,the most possible diagnosis are listed below
Migraine headache: The classical signs of migraine headache include throbbing headache, visual disturbance, nausea and vomiting(The migraine Trust, 2019).Considering this symptoms and patients past medical history of migraine shows there is a possible initial diagnosis of migraine head ache.
Hypertensive emergency : Vital signs reported from care facility and ambulance showing a sequential increase in Blood pressure .Hypertensive emergency normally diagnosed if systolic BP above 180 mm of hg and Diastolic BP above 120 mm of Hg along with severe headache, numbness and blurred vision without laboratory or clinical evidence of end organ damage. (Aronow W.S.,2017) . In ambulance patient had a seizure activity less than 30 seconds, which is likely to be diagnosed as hypertensive emergency.
Autonomic Dysreflexia (AD): AD is normally associated with patients with SCI at T6 or above. Elevated BP and associated ancillary symptoms ,like throbbing headache, visual disturbances,bradycardia, profuse sweating ,piloerection, nasal congestion links to another possible diagnosis of AD.Seizure ,hypertensive encephalopathy,myocardial infarction and intracranial hemorrhage are the life threatening complications of AD(Murray et.al,2018)
PHYSICAL EXAMINATION/VITAL SIGNS
Mr X 52 year old man is quadriplegic,alert and oriented.Above average built.Appears pallor.
Temp: 36.2 degree celcious
Pulse rate:42 beats /minute
BP:220/110 mm of hg
RR:22 breaths /minute
Appears pallor/cold clammy to touch.
Profuse sweating above thorax.
Piloerection/goose bumbs present.
Stage 2 pressure injury on both elbows.Wound bed pink with partial thickening on the margins. No slough present .Allevien dressing on.
Supra pubic Catheter site intact/no oozing or signs of infection.
No cyanosis/rashes/clubbing if nails.Reff
Head : Normocephalic/Alopecia present/no scalp lesions.
Eyes :Blurred vision and visual disturbances present/Right and left pupil shows 5mm dilation with sluggish reaction to light. white sclera /pink conjunctiva. Extra ocular movements intact.
Pupillary response to light is an important metric to the activity of sympathetic and parasympathetic nervous system (Hall & Chilcott,2018)
Ears: No tinnitus/otoscopic examination not done as patient uncomforatable. Good acquity to whispering test
Nose: Nasal congestion present/ non deviated nasal septum/no epistaxis/ rhinnorhea/pink mucosa
Throat/mouth: no dryness /clotting of tongues/oral thrush.Pink oral mucosa/good dentition.pharynx/tonsils/uvula visible no infection noted.
Neck: poor range of motion
Lymph nodes: no palpable lymph nodes.(NOTES Reff
Thorax and lungs: No history of asthma allergy
Inspection: no shortness of breath/dyspnoea .thorax symmetrical,no visible intercoastal musle retractions
Palpation:No tenderness/bruising.Posterior chest expansion/spinous process not palpated due to quatriplegia.
Percussion:no hyperresonance / signs of pneumothorax/pleural effusion
Auscultation:Air entry bilaterally equal/no abnormal lung sound.
Cardiovascular: No known cardiac problems.
Inspection : tetraplegic limbs/no varicose veins/no edema /pressure ulcers in both elbows.
Palpation: Cold and clammy skin/All puses very feable/Pulse Rate :42 beats /minute(REFFFF)
Auscultation: heart sounds S1 and S2 heard.No S3/S4 /no diastolic murmers.
Major blood vessels:Carotid artery/ JVP
Skin cool and clammy/no scars/no dilated veins/no visible peristalsis/no umbilical herniation .
Contor is flat/protuberant/symmetrical abdomen
Supra pubic Catheter present
Abdomen upper right and left quadrants soft/tendeness noted in lower quadrant
Liver/spleen/kidneys/spleen unable to palpate.
Blader scan shows 1800 ml urine.(REFF
Auscultation:bowel sounds 12 per minute
Mental Status: Alert/oriented/moderate impact on thought process after seizure activity.
CN 1: not tested
CN 2:Visual acuity not intact/blurring of vision(BB)
CN 3,4,6: No ptosis/Pupillary Light Reflex (PLR) shows both right and left pupil 5 mm each with sluggish reaction to light.PLR shows the dilation and constriction of pupils in response to sympathetic and para sympathetic modulations. (Hall & Chilcott,2018)
CN 5: Masetter and tempora strength not tested