Nervous System Case Study

History
A 73-year-old female is brought to the ER via ambulance. She is found lying on the
floor of her kitchen by her daughter. Patient is awake but unable to speak or move her
right extremities. Daughter reports she has witnessed her mother have two short spells
of numbness and clumsiness with her right hand over the past 3 months. She urged
her mother to see her family physician but does not believe she has followed through.
Medication for hypertension and nonsteroidal anti-inflammatory drugs (NSAIDS) for
arthritis were brought to the ER by the daughter, who states she believes her mother is
hoarding her medication and not taking it as often as prescribed.

Past Medication History

Hypertension, arthritis in left hip requiring use of quad cane for walking long
distances; had a hysterectomy at age 46 for endometriosis

Family and Social History

Patient is widowed and lives alone. She is a retired school bus driver. Daughter reports
she is active in her church and tends a large vegetable garden each year. Multiple
family members are hypertensive, but history is negative for neurological diseases.

Physical Examination
Patient is awake and calm. She is unable to answer any questions and does not follow
any commands for moving right extremities and does not spontaneously move right
extremities. Follows all commands with left extremities, and muscle strength appears
normal for her age. Her blood pressure was 168/108.

Diagnostic Imaging
MRI of head shows area of hemorrhage in the cerebral area on left side of brain. X-
rays of head, spine, and hips were negative for fractures.

Diagnosis
Left CVA with right hemiplegia

Plan of Treatment
1. Admit to ICU and monitor for additional bleeding and worsening of symptoms.
2. Aggressive medical treatment to reduce blood pressure.
3. Begin rehabilitation with PT, OT, and speech therapy.
4. 4. Referral to medical social worker to begin discussions with patient, family,
and rehabilitation therapists to determine alternate living arrangements.

6/19/18
Please answer the following questions regarding this case study. This is an opportunity
to see how Med Term will be used in realistic events in the healthcare field. To answers
some questions, you may need to use information from other chapters, in a medical
dictionary, or online.
1. Pick out at least five bolded medical terminology words from the case study and
dissect them into their prefixes, suffixes and/or combining forms/word roots. Define
each element and then define the whole word. See one example done for you.
Example: Arthritis
Prefix:
Word Root: arthr (joint)
Suffix: -itis (inflammation)
Whole word meaning: Inflammation of the joints.

A.
B.
C.
D.
E.

2. Name and define the following abbreviations used in this medical record:
ER
MRI
ICU
PT
OT
CVA
3. Do you think taking skeletal x-rays was a necessary part of this patient’s evaluation?
Why or why not?

6/19/18
4. In the ER the patient was(A) unable to speak and (B)move the left extremities. What
are the medical terms for each of these symptoms?
A.
B.
5. Explain why bleeding was found on the left side of the brain, but paralysis was on the
right extremities? Use proper med term to explain.

6/19/18