George is a 59-year-old lawyer who presents to the emergency room with weakness and numbness of his right side that began while playing golf this morning. George says he had an unusual headache when he first woke up, but he was looking forward to golf and the headache was not bad enough to prevent him from golfing. While on the golf course, George suddenly had an episode of weakness. After this weakness, George realized he could not move his right side, could not speak, fell off his seat in the golf cart, and could not get up. Georges friends called 911 to bring him to the emergency room. This episode with neurological deficits has lasted longer than 1 hour and persists while the patient is in the emergency room. George has a history of hypertension, diabetes mellitus type 2, and 30-pack-years of smoking.
Case Questions
1. What should the initial history and physical examination include? (make a list of the interventions that would be performed on examination of this patient)
2. What are the differential diagnoses for this patient?
3. What is the most likely diagnosis for this patient? Explain your answer.
4. What treatments will be used for the initial management of the patients condition?
5. What factors are contraindications for thrombolytic therapy?
6. What are the goals in stroke management?
Sample solution
Dante Alighieri played a critical role in the literature world through his poem Divine Comedy that was written in the 14th century. The poem contains Inferno, Purgatorio, and Paradiso. The Inferno is a description of the nine circles of torment that are found on the earth. It depicts the realms of the people that have gone against the spiritual values and who, instead, have chosen bestial appetite, violence, or fraud and malice. The nine circles of hell are limbo, lust, gluttony, greed and wrath. Others are heresy, violence, fraud, and treachery. The purpose of this paper is to examine the Dante’s Inferno in the perspective of its portrayal of God’s image and the justification of hell.
In this epic poem, God is portrayed as a super being guilty of multiple weaknesses including being egotistic, unjust, and hypocritical. Dante, in this poem, depicts God as being more human than divine by challenging God’s omnipotence. Additionally, the manner in which Dante describes Hell is in full contradiction to the morals of God as written in the Bible. When god arranges Hell to flatter Himself, He commits egotism, a sin that is common among human beings (Cheney, 2016). The weakness is depicted in Limbo and on the Gate of Hell where, for instance, God sends those who do not worship Him to Hell. This implies that failure to worship Him is a sin.
God is also depicted as lacking justice in His actions thus removing the godly image. The injustice is portrayed by the manner in which the sodomites and opportunists are treated. The opportunists are subjected to banner chasing in their lives after death followed by being stung by insects and maggots. They are known to having done neither good nor bad during their lifetimes and, therefore, justice could have demanded that they be granted a neutral punishment having lived a neutral life. The sodomites are also punished unfairly by God when Brunetto Lattini is condemned to hell despite being a good leader (Babor, T. F., McGovern, T., & Robaina, K. (2017). While he commited sodomy, God chooses to ignore all the other good deeds that Brunetto did.
Finally, God is also portrayed as being hypocritical in His actions, a sin that further diminishes His godliness and makes Him more human. A case in point is when God condemns the sin of egotism and goes ahead to commit it repeatedly. Proverbs 29:23 states that “arrogance will bring your downfall, but if you are humble, you will be respected.” When Slattery condemns Dante’s human state as being weak, doubtful, and limited, he is proving God’s hypocrisy because He is also human (Verdicchio, 2015). The actions of God in Hell as portrayed by Dante are inconsistent with the Biblical literature. Both Dante and God are prone to making mistakes, something common among human beings thus making God more human.
To wrap it up, Dante portrays God is more human since He commits the same sins that humans commit: egotism, hypocrisy, and injustice. Hell is justified as being a destination for victims of the mistakes committed by God. The Hell is presented as being a totally different place as compared to what is written about it in the Bible. As a result, reading through the text gives an image of God who is prone to the very mistakes common to humans thus ripping Him off His lofty status of divine and, instead, making Him a mere human. Whether or not Dante did it intentionally is subject to debate but one thing is clear in the poem: the misconstrued notion of God is revealed to future generations.
References
Babor, T. F., McGovern, T., & Robaina, K. (2017). Dante’s inferno: Seven deadly sins in scientific publishing and how to avoid them. Addiction Science: A Guide for the Perplexed, 267.
Cheney, L. D. G. (2016). Illustrations for Dante’s Inferno: A Comparative Study of Sandro Botticelli, Giovanni Stradano, and Federico Zuccaro. Cultural and Religious Studies, 4(8), 487.
Verdicchio, M. (2015). Irony and Desire in Dante’s” Inferno” 27. Italica, 285-297.
Sample Answer
Sample Answer
Case Analysis: George’s Neurological Episode
1. Initial History and Physical Examination
When assessing George in the emergency room, the following interventions should be included in the initial history and physical examination:
History:
– Onset and Duration: Clarify the exact time of onset of weakness and numbness.
– Symptoms: Detailed assessment of neurological deficits (specific weakness, speech difficulties).
– Headache History: Description of the unusual headache (intensity, duration, location).
– Medical History: Review of past medical history, including hypertension, diabetes, and smoking history.
– Medications: List of current medications (including anticoagulants or antiplatelets).
– Allergies: Any known allergies to medications or substances.
– Family History: Any familial history of stroke or cardiovascular diseases.
– Social History: Alcohol consumption, illicit drug use, and lifestyle factors.
Physical Examination:
– Vital Signs: Assess blood pressure, heart rate, respiratory rate, and temperature.
– Neurological Examination: – Level of consciousness (Glasgow Coma Scale).
– Cranial nerve function (especially speech and facial droop).
– Motor strength assessment (upper and lower extremities).
– Sensory examination (light touch, proprioception).
– Coordination and gait evaluation.
– Cardiovascular Examination: Heart sounds, rhythm, and any murmurs.
– Respiratory Examination: Lung sounds and effort.
– Abdominal Examination: Check for any tenderness or masses.
2. Differential Diagnoses
Considering George’s symptoms and medical history, the differential diagnoses may include:
– Ischemic Stroke: Most likely given the sudden onset of weakness and speech issues.
– Hemorrhagic Stroke: Could be possible due to the headache and acute neurological deficit.
– Transient Ischemic Attack (TIA): Although symptoms last longer than an hour, it’s still a consideration.
– Brain Tumor or Abscess: Possible if there are other neurological signs present.
– Seizure Activity: Postictal state could present with weakness but typically resolves quicker.
– Peripheral Nerve Injury: Less likely given the sudden onset and accompanying symptoms.
3. Most Likely Diagnosis
The most likely diagnosis for George is an ischemic stroke, specifically a possible middle cerebral artery (MCA) stroke. This conclusion is based on:
– The sudden onset of right-sided weakness and numbness.
– The accompanying speech difficulties (expressive aphasia or dysarthria).
– The duration of symptoms exceeding one hour, which exceeds TIA criteria.
4. Initial Management Treatments
The initial management for suspected ischemic stroke includes:
– Immediate Neuroimaging: CT scan without contrast to rule out hemorrhagic stroke.
– Thrombolytic therapy (if indicated): Administer alteplase (tPA) within 3 to 4.5 hours of symptom onset if no contraindications are present.
– Intravenous fluids: Ensure adequate hydration but avoid overhydration.
– Blood glucose monitoring: Manage hyperglycemia as it can worsen outcomes.
– Continuous monitoring: Vital signs and neurological status monitoring in a stroke unit or intensive care if necessary.
5. Contraindications for Thrombolytic Therapy
Factors that contraindicate thrombolytic therapy include:
– History of hemorrhagic stroke or intracranial hemorrhage.
– Active bleeding disorders or recent major surgery.
– Severe hypertension (e.g., systolic BP above 185 mmHg).
– Intracranial neoplasm or arteriovenous malformation.
– Rapidly improving symptoms (suggesting a TIA rather than a full stroke).
– Age over 80 years with other risk factors (relative contraindication).
6. Goals in Stroke Management
The primary goals in stroke management include:
1. Rapid Diagnosis and Treatment Initiation: Minimize time to treatment to improve outcomes (time is brain).
2. Restoration of Cerebral Blood Flow: Through thrombolytics or endovascular therapy if indicated.
3. Management of Risk Factors: Control hypertension, blood glucose levels, and other comorbidities.
4. Prevent Complications: Monitor for respiratory issues, deep vein thrombosis, and pressure ulcers.
5. Rehabilitation Planning: Early assessment for rehabilitation needs to optimize recovery potential.
6. Education and Support for Patient and Family: Provide information on stroke recovery, lifestyle modifications, and support resources.
In summary, George’s presentation is consistent with an ischemic stroke, likely secondary to his vascular risk factors. Immediate assessment and appropriate management are crucial to optimize his recovery potential.
