Marjory Taylor is 88 yo. She has lived in a residential aged care facility for the past 4 years because she developed Parkinson’s disease, subsequently Alzheimer’s disease, and was unable to continue living independently. Marjory uses a 4 wheeled mobility aid but is noted to be unsteady on her feet and impulsive in her actions, unable to wait for assistance to mobilise. Her gait is shuffling, and she leans forward to walk. Marjory is forgetful and has slowed speech, but she does not exhibit significant confusion or disorientation. Today the carers found that Marjory was difficult to rouse for breakfast. The Registered Nurse on duty was called and he undertook assessments. Collect cues Medical history: Atrial fibrillation Hypertension (usual blood pressure 130/80 mmHg) Parkinson’s (Stage 2) Dementia – Alzheimer's - Mild Medications: apixaban 2.5 mg orally, twice daily enalapril 5 mg orally, daily Sinemet (levodopa 100 / carbidopa 25 mg) orally, three times daily From Marjory’s notes: 4 weeks ago: “Marjory was found on the floor in her bathroom after a fall. She had a small lump on the left side of her head. The lump overlapped the posterior frontal and anterior parietal areas, about 8 cm superior to her ear. She was not unconscious when she was found. Neurological observations were undertaken as per protocol for 48 hours, but no deterioration was noted. GCS, pupillary response, limb movement, vital signs and blood glucose level were all within normal ranges. No confusion or drowsiness noted.” For the past 3 weeks, Marjory has periodically complained of a headache which has been relieved by paracetamol. Today: Vital signs: Respiratory rate: 20 bpm SpO2: 98% on room air BP: 150/95 mmHg (MAP 113 mmHg) HR: 100 bpm Temp: 36.8oC Pain: reporting "my head really hurts”, but can give no further information Neurological observations: GCS: Best eye response: 3 (Marjory will open her eyes briefly when her name is called) Best verbal response: 3 (when asked if she knows where she is, Marjory responds with words which make no sense) Best motor response: 6 (Response to request is slow) Pupillary response: Both pupils 4 mm in size Left pupil sluggish reaction to light: right pupil normal reaction to light Limb movement: Slowed response to instructions Left lower and upper limbs – normal power Right lower limb – severe weakness Right upper limb – mild weakness Take Action Marjory is transported to hospital by ambulance. A CT brain was performed, and a subdural haematoma was identified in the left superior frontal parietal area. With reference to anatomy and by using physiological and pathophysiological mechanisms, explain step-by-step the development of these cues of Marjory’s presentation.
Consider the person
Marjory Taylor is 88 yo. She has lived in a residential aged care facility for the past 4 years because she developed Parkinson’s disease, subsequently Alzheimer’s disease, and was unable to continue living independently.
Marjory uses a 4 wheeled mobility aid but is noted to be unsteady on her feet and impulsive in her actions, unable to wait for assistance to mobilise. Her gait is shuffling, and she leans forward to walk.
Marjory is forgetful and has slowed speech, but she does not exhibit significant confusion or disorientation.
Today the carers found that Marjory was difficult to rouse for breakfast. The Registered Nurse on duty was called and he undertook assessments.
Collect cues
Medical history:
Atrial fibrillation
Hypertension (usual blood pressure 130/80 mmHg) Parkinson’s (Stage 2)
Dementia – Alzheimer's - Mild
Medications:
apixaban 2.5 mg orally, twice daily
enalapril 5 mg orally, daily
Sinemet (levodopa 100 / carbidopa 25 mg) orally, three times daily
From Marjory’s notes:
4 weeks ago: “Marjory was found on the floor in her bathroom after a fall. She had a small lump on the left side of her head. The lump overlapped the posterior frontal and anterior parietal areas, about 8 cm superior to her ear. She was not unconscious when she was found. Neurological observations were undertaken as per protocol for 48 hours, but no deterioration was noted. GCS, pupillary response, limb movement, vital signs and blood glucose level were all within normal ranges. No confusion or drowsiness noted.”
For the past 3 weeks, Marjory has periodically complained of a headache which has been relieved by paracetamol.
Today:
Vital signs:
Respiratory rate: 20 bpm
SpO2: 98% on room air
BP: 150/95 mmHg (MAP 113 mmHg)
HR: 100 bpm
Temp: 36.8oC
Pain: reporting "my head really hurts”, but can give no further information
Neurological observations:
GCS:
Best eye response: 3 (Marjory will open her eyes briefly when her name is called)
Best verbal response: 3 (when asked if she knows where she is, Marjory responds with words which make no sense)
Best motor response: 6 (Response to request is slow)
Pupillary response:
Both pupils 4 mm in size
Left pupil sluggish reaction to light: right pupil normal reaction to light Limb movement:
Slowed response to instructions
Left lower and upper limbs – normal power
Right lower limb – severe weakness
Right upper limb – mild weakness
Take Action
Marjory is transported to hospital by ambulance.
A CT brain was performed, and a subdural haematoma was identified in the left superior frontal parietal area.
With reference to anatomy and by using physiological and pathophysiological mechanisms, explain step-by-step the development of these cues of Marjory’s presentation.
Step by step
Solved in 3 steps
