Complete the three case studies below.

I. Nate Greene, age 59, has type 2 diabetes that has not been managed well with oral medication. Recently his doctor added insulin to this medication regimen. Mr. Greene accidentally injected too much insulin and had a tonic-clonic seizure, which his wife saw and called an ambulance. After Mr. Greene has been stabilized in the hospital emergency department, Mrs. Greene is crying in the hall. “I cannot bear anymore!” she says. “First he gets diabetes and now he has epilepsy!”

Physical Examination
• Vital signs normal
• Level of consciousness decreased: confused, disoriented to time and place, not a person
• Obese, with abdominal fat distribution

Laboratory Results
• Initial blood glucose in the ambulance: 46 mg/dl
• Blood glucose after treatment: 116 mg/dl

1. Provide how you would respond to Mrs. Greene?
2. Did Mr. Green have a partial or a generalized seizure? What is the pathophysiologic difference between these two types?
3. What is the “tonic” part of the seizure?
4. What is the “clonic” part of the seizure?
5. Why did Mr. Greene’s confusion and disorientation not resolve immediately when he received intravenous glucose?
6. After he recovered that afternoon, Mr. Greene said his leg and arm muscles were aching. What most likely caused his muscle aching?

II. Mrs. Czerny, age 81, was diagnosed with Alzheimer’s disease when she had difficulty learning the names of her new grandchildren and then got lost several times on the way to her local grocery store. Her family had noticed several years of increasing forgetfulness before her diagnosis but had thought that was part of aging. Over the next 4 years after diagnosis, Mrs. Czerny became more in need of care, because of decreased judgment and self-care ability, and her family hired a full-time caregiver. Eventually, she failed to recognize her family members when they came to visit her, which distressed them greatly. A nurse referred them to a family support group, which they found very helpful.

1. What two classic pathologic changes that contribute to neuronal death are visible in the brain tissue of a person who had Alzheimer’s disease? Describe each briefly.
2. How soon do clinical manifestations of Alzheimer’s disease arise after the pathologic changes in the brain begin?
3. Mrs. Czerny’s initial symptom was forgetfulness, which is the most common initial manifestation of Alzheimer’s disease. What portion of her brain was most affected by the pathologic changes at that time?
4. “First she kept forgetting, and now she has poor judgment too,” said Mrs. Czerny’s son. “I understand that the memory part of her brain is damaged, but now I see more problems. How is this possible?” How should a nurse respond?

III. Mr. Tom Costa, age 71, had a stroke last year that made his right upper and lower extremities quite weak. He has smoked for 55 years and is obese. He was diagnosed with atrial fibrillation, high blood pressure, and type 2 diabetes mellitus while he was hospitalized with his stroke. His father died of a heart attack at age 50; his paternal grandfather had a stroke and died a year later after a second stroke. His mother and both of her parents had type 2 diabetes.

1. What technical term should be used to describe Mr. Costa’s weak right upper and lower extremities?
2. The lesion that caused his motor dysfunction is located on which side of his brain?
3. Given his history, is it more likely that Mr. Costa had an ischemic or a hemorrhagic stroke?
4. What is a potential relationship between Mr. Costa’s atrial fibrillation and his stroke?
5. What is a potential relationship between Mr. Costa’s other risk factors and his stroke? Provide strategies that Mr. Costa can integrate into his lifestyle to help him reduce his risk factors.
6. Mrs. Costa says, “Tom’s grandfather had a stroke and he could not talk any more, but he could walk. Now my husband has a stroke, and he can talk but he cannot walk. I do not understand this! Why?” Explain to Mrs. Costa.
7. “The doctor said to call her if I had a TIA,” says Mr. Costa. “Why should I do that? A TIA goes away.” Explain to Mr. Costa.