SITUATION: Mr Chong was brought into Emergency Department (ED) last night by ambulance after collapsing at home. The ED Registered Nurse reported that Mr Chong was alert and orientated to person, time and place on admission. He has global aphasia, left gaze preference, right homonymous hemianopia (field cut), right facial droop, dysarthria, and right hemiplegia. CT angiography showed a left Middle Cerebral Artery (MCA) occlusion (Fig 1). 12-lead ECG showed Atrial Fibrillation (Fig 2). BACKGROUND Mr Chong has a past medical history of Coronary Artery Disease, Coronary Artery Bypass Grafting, Atrial Fibrillation and previous TIA (Transient Ischaemic Attack) three month ago. Mr Chong is retired and independent with activities of daily living. He speaks simple English. Mr Chong lives with his wife and two sons. ASSESSMENT His last Glasgow Coma Scale (GCS) is between 13-14 (disorientated and occasionally confused to time and place) and other vital signs are within normal limits. His BGL: 6.3mmol/L. He has an abrasion and bruising to his right forehead. His wife gave him some sips of water when I was on my break and he had a coughing fit that lasted for at least five minutes. His voice is slightly hoarse and started coughing each time he tries to speak. RECOMMENDATION Continue neurological observations. Mr Chong will have to be kept Nil by Mouth (NBM) until reviewed by the Speech Therapist as he has a high risk of aspiration due to dysphagia. I think we need to reinforce the NBM to his wife.
SITUATION: Mr Chong was brought into Emergency Department (ED) last night by ambulance after collapsing at home. The ED Registered Nurse reported that Mr Chong was alert and orientated to person, time and place on admission. He has global aphasia, left gaze preference, right homonymous hemianopia (field cut), right facial droop, dysarthria, and right hemiplegia. CT angiography showed a left Middle Cerebral Artery (MCA) occlusion (Fig 1). 12-lead ECG showed Atrial Fibrillation (Fig 2).
BACKGROUND Mr Chong has a past medical history of Coronary Artery Disease, Coronary Artery Bypass Grafting, Atrial Fibrillation and previous TIA (Transient Ischaemic Attack) three month ago. Mr Chong is retired and independent with activities of daily living. He speaks simple English. Mr Chong lives with his wife and two sons.
ASSESSMENT His last Glasgow Coma Scale (GCS) is between 13-14 (disorientated and occasionally confused to time and place) and other vital signs are within normal limits. His BGL: 6.3mmol/L. He has an abrasion and bruising to his right forehead. His wife gave him some sips of water when I was on my break and he had a coughing fit that lasted for at least five minutes. His voice is slightly hoarse and started coughing each time he tries to speak. RECOMMENDATION Continue neurological observations. Mr Chong will have to be kept Nil by Mouth (NBM) until reviewed by the Speech Therapist as he has a high risk of aspiration due to dysphagia. I think we need to reinforce the NBM to his wife.
Question 2
Describe the signs and symptoms exhibited by Mr Chong that suggested he has dysphagia. Explain the pathophysiology behind why Mr Chong is at risk of aspiration and support your discussion using assessment data from Mr Chong’s medical record and case study; and evidence from peer-reviewed literature?
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