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Practice Guidelines for Family Nurse Practitioners E Book 5th Edition, (Ebook PDF)
University ofSouth Alabama,College ofNursing Mobile,Alabama
20.Measures ofOxygenation and Ventilation,21.The Chest X-Ray,33.Oxygen Supplementation,34.Mechanical Ventilatory Support
Diantha D.Miller,MSN,APRN,BC,ACNP,PNP
Adjunct Faculty
University ofSouth Alabama Mobile,Alabama;
Nurse Practitioner
Laser and Skin Care Center ofMobile Mobile,Alabama
70.Eye,Ear,Nose,and Throat Disorders
Sally K.Miller,PhD,APRN,BC,ACNP,ANP,GNP,FAANP
Chair,Department ofPhysiologic Nursing
University ofLas Vegas School ofNursing Las Vegas,Nevada
67.Autoimmune Diseases,85.Managing the Surgical Patient
Charlene M.Myers,MSN,APRN,BC,ACNP,CCRN
Clinical Assistant Professor
Program Coordinator,Adult Acute Care Nurse Practitioner Program
University ofSouth Alabama,College ofNursing Mobile,Alabama
1.Cerebrovascular Accidents: Brain Attack,2.Structural Abnormalities,3.Peripheral Neuropathies,4.Neurologic Trauma,5.Central Nervous System Disorders,6.Seizure Disorders,7.Dementia,23.Pulmonary Function Testing,28.Chest Wall and Secondary Pleural Disorders,35.Peptic Ulcer Disease,36.Liver Disease,37.Biliary Dysfunction,38.Inflammatory Gastrointestinal Disorders,39.Anatomic Intestinal Disorders,40.Gastrointestinal Bleeding,41.Urinary Tract Infections,42.Renal Insufficiency and Failure,43.Benign Prostatic Hyperplasia,44.Renal Artery Stenosis, 45.Nephrolithiasis,75.Management ofthe Patient in Shock
Sandra J.Ogawa,MSN,APRN,BC,ACNP
Acute Care Nurse Practitioner,Thoracic Surgery
Assistant Coordinator,Esophageal Disease Center Heart Institute at St.Joseph’s Medical Center Phoenix,Arizona
84.Hospital Admission Considerations
Marian Elizabeth Peters,MSN,RN,WHNP,CNS
Clinical Assistant Professor
University ofSouth Alabama Mobile,Alabama
69.Ectopic Pregnancy and Sexually Transmitted Infections
Luisa Maria Schulman,MSN,RN,ANP-C,CCRN
Adult Nurse Practitioner,Private Practice Pasadena,California; Lecturer
California State University,Los Angeles School ofNursing Los Angeles,California
66.HIV/AIDS and Opportunistic Infections
Martha N.Surline,MS Director ofStudent Services
University ofSouth Alabama,College ofNursing Mobile,Alabama
76.Nutritional Considerations
Paula K.Vuckovich,PhD,APRN,BC
Assistant Professor,School ofNursing
California State University Los Angeles,California; ReliefSupervisor
Aurora Las Encinas Hospital Pasadena,California
74.Psychosocial Problems in Acute Care
Elizabeth A.Vande Waa,PhD
Associate Professor,Department ofAdult Health
University ofSouth Alabama,College ofNursing Mobile,Alabama
78.Poisoning and Drug Toxicities
John A.Vande Waa,DO,PhD
Associate Professor ofMedicine
Consultant in Infectious Diseases,Immunodeficiencies,Traveler’s Health University ofSouth Alabama Mobile,Alabama
80.Infections
Colleen R.Walsh,RN,MSN,APRN,BC,ACNP,ONC,CS
Faculty,Graduate Nursing
University ofSouthern Indiana,College ofNursing and Health Professions
Evansville,Indiana;
Acute Care Nurse Practitioner
Jenkins Community Hospital
Jenkins,Kentucky
54.Arthritis,55.Subluxations and Dislocations,56.Soft Tissue Injury,57.Fractures, 58.Compartment Syndrome,59.Back Pain Syndromes,65.Other Common Cancers
Gail Washington,DNS,RN
Assistant Professor
California State University,Los Angeles
School ofNursing
Los Angeles,California
69.Ectopic Pregnancy and Sexually Transmitted Infections
Carolyn Mathis White,JD,MSN,APRN,BC,FNP,PNP,CCRN
Clinical Assistant Professor
University ofSouth Alabama
Mobile,Alabama;
Nurse Practitioner
Victory Health Partners
Mobile,Alabama
70.Eye,Ear,Nose,and Throat Disorders; 86.Guidelines for Health Promotion and Screening
Kimberly A.Williams,DNSc,APRN,BC,ANP,PMHNP
Assistant Professor
University ofSouth Alabama,College ofNursing Mobile,Alabama;
Adult Health Nurse Practitioner
GulfCoast Medical Center,Biloxi,Mississippi
Garden Park Medical Center,Gulfport,Mississippi
Hancock Medical Center,Bay St.Louis,Mississippi
Memorial Hospital,Gulfport,Mississippi
Ocean Springs Hospital,Ocean Springs,Mississippi
Select Specialty Hospital,Gulfport,Mississippi
88.Immunization Recommendations
Preface
Practice Guidelines for Acute Care Nursing Practitioners is a succinct and comprehensive pocket text for advanced practice nurses.The text is organized in a systematic fashion,addressing over 250 ofthe most common conditions experienced by adult patients in acute care.Using an easy-to-read outline format,coverage ofeach condition includes defining terms,incidence/predisposing factors,subjective and physical examination findings,diagnostic tests,and management strategies.
The text has been written to provide the practitioner with a quick overview ofevidence-based practice guidelines.In this light,the text builds on previous knowledge ofanatomy,physiology,and pathophysiology concepts that have not been separately emphasized.Although many practitioners may be highly specialized,this text was designed as a useful tool for the entire scope ofacute care nursing practice,including settings such as clinics,emergency departments,medical/surgical departments in hospitals,as well as critical care units.Although this text was developed based on research and expertise,we also feel strongly that collaborative practice with other experts and clinicians is essential to successfully meeting patient goals.
ThomasW.Barkley,Jr. Charlene M.Myers
Acknowledgments
We gratefully acknowledge the outstanding contributors and reviewers for this text. Without the expertise ofthese scholars,this work would not have been possible.
We also thank the following people at Elsevier:
Thomas Eoyand,former Editor,for believing in our potential as editors for the first edition
Barbara Nelson Cullen,former Executive Publisher
Sandra Brown,Senior Acquisitions Editor
Sophia Oh Gray,Developmental Consultant
Cheryl Abbott,Senior Project Manager
whose combined efforts have produced what we believe is a state-of-the art,evidence-based,excellent resource for the profession.
Thomas W.Barkley,Jr. CharleneM.Myers
Reviewers
Nancy J.Bekken,RN,MSN,CCRN
Spectrum Health Grand Rapids,Michigan
Susan Duhon-Johnston,MSN,FNP-BC
Hospital-based Internal Medicine
Ochsner Health System
New Orleans,Louisiana
Lynn S.Eckhardt,BSN,MSN,NP
Director ofDementia Clinic Neurology Department
Ochsner Health System
New Orleans,Louisiana
Pamela L.Isbell,MSN,CEN
StaffNurse,ReliefCharge Nurse
Orlando Regional Medical Center Orlando,Florida
Suzanne Lazare-Ellis,RN,MSN, CCRN,CNS
Intensive Care Unit StaffNurse
San Francisco VA Medical Center
San Francisco,California
Allyson E.Mobley,MSN,CRNP
Neurology
Alabama Neurological Institute Birmingham,Alabama
Ted Rigney,MS,RNP,CCRN,ACNP Assistant Director Nurse Practitioner Program
University ofArizona College of Nursing Tucson,Arizona
Nancy Evans Stoner,RN,MSN Hospital ofthe University of Pennsylvania Clinical Nutrition Support Service Philadelphia,Pennsylvania
Scott Carter Thigpen,RN,MSN, CCRN,CEN
Assistant Professor ofNursing South Georgia College Douglas,Georgia
Joseph E.Williams,RN,MSN, ACNP-C,ANP-C
Lead Nurse Practitioner Hospitals Division,Department of Internal Medicine
Ochsner Health System New Orleans,Louisiana
Section ONE
Contents
Management of Patients With Neurologic Disorders
1 Cerebrovascular Accidents:Brain Attack, 3
CHARLENE M.MYERS
TIA—Transient Ischemic Attack, 3
Stroke/Brain Attack, 8
Ischemic Stroke, 9
Hemorrhagic Stroke, 14
2 Structural Abnormalities, 23
CHARLENE M.MYERS
Aneurysm, 23
Hydrocephalus, 27
Space-Occupying Lesions (Brain Tumors), 28
3 Peripheral Neuropathies,34
CHARLENE M.MYERS
Guillain-Barré Syndrome, 34
Myasthenia Gravis, 38
4 Neurologic Trauma, 43
CHARLENE M.MYERS
Head Trauma/Traumatic Brain Injury, 43
Spinal Cord Trauma, 51
5 Central Nervous System Disorders, 63
CHARLENE M.MYERS
Meningitis, 63
Cerebral Abscess, 67
Encephalitis, 68
Encephalopathy, 70
6 Seizure Disorders, 72
CHARLENE M.MYERS
Dementia, 82
CHARLENE M.MYERS
Section TWO
Management of Patients With Cardiovascular Disorders
8 Cardiovascular Assessment, 91
THOMAS W.BARKLEY,JR.
9 Hypertension, 95
THOMAS W.BARKLEY,JR.AND JENNIFER RAMOS JAVIER
10 Coronary Artery Disease and Hyperlipidemia, 109
General Physical Examination Guidelines for Wound Assessment, 843
Wound-Specific Physical Examination Findings, 844
Laboratory/Diagnostic Findings, 845
Management, 846
Selected Treatment Options, 847
80 Infections, 851
JOHN A.VANDE WAA
Hospital-Acquired Infections, 851
Community-Acquired Infections, 858
81 Chest,Abdominal,and Eye Trauma, 863
THOMAS W.BARKLEY,JR.
Chest Trauma, 863
Abdominal Trauma, 867
Penetrating Eye Trauma, 870
82 Solid Organ Transplantation, 871
KIMBERLY RILEY BRYAN
Solid Organ Transplantation, 871
Immunosuppression and Organ Rejection, 872
Common Medical Complications in Solid Organ Transplantation, 875
Common Infections, 876
Kidney Transplantation, 878
Liver Transplantation, 879
Lung Transplantation, 880
Heart Transplantation, 881
Pancreas Transplantation, 882
Intestinal Transplantation, 883
83 Burns, 886
THOMAS W.BARKLEY,JR.
84
Hospital Admission Considerations, 890
SANDRA J.OGAWA AND THOMAS W.BARKLEY,JR.
History and Physical Examination (H&P), 890
Admission Orders, 895
Progress Note, 896
Presentation ofPatient, 897
Procedure Note, 897
Discharge Summary, 898
Prescriptions, 899
General Guidelines for Admission to an Intensive Care Unit (ICU), 899
General Guidelines for Discharge From an ICU, 901
85 Managing the Surgical Patient, 902
SALLY K.MILLER
Preoperative Assessment, 902
Postoperative Care, 907
Section THIRTEEN
Health Promotion
86 Guidelines for Health Promotion and Screening, 913
CAROLYN MATHIS WHITE
Visionary Plan for Health, 913
Prevention, 916
Prevention and Health Promotion in Clinical Practice, 917
87 Major Causes ofMortality in the United States, 931
BARBARA ANN SHELTON BROOME
Leading Causes ofDeath in the U.S., 931
Risk Assessment, 931
88 Immunization Recommendations, 939
KIMBERLY A.WILLIAMS
Immunization, 939
APPENDIX
2007 Asthma Guidelines,National Heart,Lung,and Blood Institute, 957
SECTION ONE
Management of Patients With Neurologic Disorders
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Cerebrovascular Accidents: Brain Attack
CHARLENE M.MYERS
Hemorrhagic stroke, 431
Ischemic stroke, 434.91
Stroke/brain attack, 434.91
Transient ischemic attack, 436
TIA—TRANSIENT ISCHEMIC ATTACK
I.Definition
A. Classic definition:sudden or rapid onset ofneurologic deficit caused by focal ischemia that lasts for a few minutes and resolves completely within 24 hours
B. Recently proposed revision ofclassic definition:briefepisode ofneurologic dysfunction caused by focal brain or retinal ischemia,with clinical symptoms typically lasting less than 1 hour and no evidence ofacute infarction
II.Etiology/incidence/prevalence
A. Incidence is 160/100,000;prevalence is 135/100,000.
B. Carotid or vertebral artery disease
C. Cardiac emboli as seen in arrhythmia (atrial fibrillation),myocardial infarction,congestive cardiomyopathy,and valvular disease
D. Hematologic causes
1. Red blood cell (RBC) disorders
a. Increased sludging
b. Decreased cerebral oxygenation such as in severe anemia
c. Polycythemia,sickle cell anemia
2. Platelet disorders
a. Thrombocytosis
b. Thrombocytopenia
3. Myeloproliferative disorders,leukemia with white blood cell (WBC) count greater than 150,000
4. Increased viscosity/hypercoagulable conditions
a. Antiphospholipid antibody syndrome (e.g.,lupus anticoagulant, anticardiolipin antibody)
b. Oral contraceptive use
c. Antithrombin III deficiency
d. Protein S and C deficiency
e. Tissue-type plasminogen activator (t-PA) and plasminogen deficiencies
f. Patients particularly at risk for a hypercoagulable state
i. Older than age 45
ii. History ofthrombolytic event
iii. History ofspontaneous abortion
iv. Related autoimmune conditions (e.g.,lupus)
v. Stroke ofunknown cause
vi. Family history ofthrombotic events
E. Intracranial causes
1. Brain tumor
2. Focal seizure
3. Hemorrhage
a. Subdural hematoma (SDH)
b. Subarachnoid hemorrhage (SAH)
c. Intracerebral hemorrhage (ICH),which may cause cerebrovascular dysfunction due to leakage ofblood outside the normal vessels
F. Subclavian steal syndrome
1. Localized stenosis or occlusion ofa subclavian artery proximal to the source ofthe vertebral artery,so that blood is stolen from that artery
2. Blood pressure is significantly lower in the affected arm than in the opposite arm.
G. Others
1. Transient hypotension
2. Osteophytes that cause compression ofneck vessels
3. Kinking ofneck vessels during rotation ofthe head
4. Cocaine abuse
5. Hypoglycemia
III.Risk factors
A. TIA:Individuals are at risk for stroke in the months,as well as the years, immediately after the initial TIA;therefore,proper treatment ofattacks is important.Approximately one third ofstroke patients have a history ofTIA.
B. Hypertension
C. Cardiac disease,such as the following:
1. Mitral valve disease
2. Anterior wall myocardial infarction
3. Congestive myopathy
4. Arrhythmia (e.g.,atrial fibrillation)
D. Smoking
E. Obesity
F. Hyperlipidemia
G. Elevated homocysteine levels in the elderly
H. Advanced age
I. Diabetes
J. Alcohol and recreational drug abuse
IV.Clinical manifestations
A. Carotid artery syndrome
1. Ipsilateral monocular blindness (amaurosis fugax) described as similar to a shade coming down over one eye
2. Paresthesia/weakness ofcontralateral arm,leg,and face (may be episodic)
3. Dysarthria,transient aphasia
4. Ipsilateral,vascular-type headache
5. Carotid bruit may be present.
6. Microemboli,hemorrhage,and exudate may be visualized in the ipsilateral retina.
4. Sudden loss ofpostural tone in all extremities while consciousness remains intact (drop attacks)
5. Dysarthria
6. Perioral or facial paresthesia
7. Acute confusional state
V.Diagnostics/laboratory findings
A. Laboratory evaluation should include the following:
1. Complete blood count (CBC),platelet count,prothrombin time (PT), partial thromboplastin time (PTT),and international normalized ratio (INR) to detect these conditions:
a. Anemia
b. Polycythemia
c. Leukemia
d. Thrombocytopenia
e. Hypercoagulopathy
2. Anticardiolipin antibodies (immunoglobulin [Ig]G,IgM,IgA) and assay for lupus anticoagulant for suspected antiphospholipid antibody syndromes
3. Assays for antithrombin III,proteins S and C,plasminogen, and t-PA
4. Electrolytes,glucose to detect the following:
a. Hyponatremia
b. Hypokalemia
c. Hypoglycemia
d. Hyperglycemia
5. Sedimentation rate,to detect these conditions:
a. Vasculitis
b. Infective endocarditis
c. Hyperviscosity
d. Giant cell arteritis
6. Lipid profile
a. Detects hyperlipidemia
7. In selected patients,antinuclear antibody (ANA),Venereal Disease Research Laboratory test (VDRL),and toxicology screen
8. Homocysteine level
a. An amino acid
b. Elevated plasma level associated with increased risk ofvascular events
B. Computed tomography (CT) scan ofthe head
1. May reveal “silent”ischemia or ischemic images,as well as hemorrhage or infarct and SDH
2. 10% to 20% ofpatients with TIAs have an infarct in the territory relevant to their symptoms.
C. Magnetic resonance imaging (MRI),particularly diffusion-weighted imaging (DWI) and perfusion-weighted imaging (PWI)
1. More sensitive than CT scan to early pathologic changes ofischemic infarction because ofits excellent detection ofbrain edema
2. MRI is also preferred for the detection oflacunar or vertebrobasilar TIAs,or when vascular territory is not well defined.
D. Single photon emission computed tomography (SPECT)
2. Useful in identifying hemodynamically significant carotid stenosis
F. Magnetic resonance angiography (MRA)
1. Alternative to ultrasound studies
2. No contrast medium is needed.
3. Can be obtained at the same time as an MRI scan
4. Good means for assessment ofextracranial and intracranial vessels
G. Carotid Doppler ultrasound has limited usefulness.
H. Echocardiography and a 24-hour Holter monitor are used to evaluate for a cardiac source ofemboli.
I. Transesophageal echocardiography (TEE) to detect vascular tree abnormalities and stenosis
J. Cerebral angiography for patients whose symptoms suggest involvement of the carotid circulation and who are candidates for carotid endarterectomy (CEA)
K. Chest x-ray for enlarged heart
L. Blood cultures to monitor for infective endocarditis
M. Temporal artery biopsy to detect giant cell arteritis
N. Cardiac enzymes to detect an acute myocardial infarction
O. Electroencephalography (EEG) indicated in patients suspected ofhaving a seizure disorder associated with stroke,as well as an underlying toxic-metabolic disorder that may cause seizure activity
VI.Management
A. Address the following underlying risk factors:
1. Hypertension (HTN)
2. Diabetes mellitus (DM)
3. Obesity
4. Hyperlipidemia
5. Smoking
B. Carotid TIAs
1. Greater than 70% obstruction:CEA is indicated for those who are a good surgical risk.
2. Less than 30% obstruction:Surgery is not indicated.
3. Recently,carotid angioplasty and stenting (CAS) has emerged as an alternative in high-risk surgical patients,or when CEA is contraindicated for technical or medical reasons.
C. Anticoagulation ifcaused by a cardioembolic event
1. May prevent recurrent cardioembolic events
2. Begin with heparin (loading dose of5000-10,000 units for those not at risk for hemorrhagic transformation and maintenance infusion of 1000-2000 units/hour).
3. Target PTT should be 1.5 times control.
4. Follow with warfarin (Coumadin),5-15 mg PO (per os;by mouth), which is indicated for the following:
a. TIA caused by embolism arising from a mural thrombus after a myocardial infarction (MI)
b. TIA caused by embolus in patients with mitral stenosis or prosthetic heart valves
c. Recurrent TIAs despite platelet antiaggregant agents
d. INR of2 to 3 is considered therapeutic.
D. Antiplatelet therapy is useful for patients who are not candidates for surgery or warfarin therapy (those with gastrointestinal [GI] bleeding, bleeding tendencies,or severe hypertension,elderly patients who fall frequently,or uncooperative patients).
1. Aspirin (ASA [acetylsalicylic acid]) decreases incidence ofsubsequent stroke by 15% to 30% in male patients with TIAs;dose of 81-325 mg/day is as effective as higher doses and causes fewer adverse effects.
2. Clopidogrel (Plavix)
a. Antiplatelet agent that is a chemical relative ofticlopidine (Ticlid)
b. Causes far fewer adverse hematologic effects
c. May cause thrombotic thrombocytopenia purpura (TTP) during the first 2 weeks oftreatment
d. Indicated for secondary prevention ofischemic stroke,MI,and other vascular events in patients who cannot tolerate ASA,or in patients who were taking ASA at the time ofthe event
a. Available as fixed-dose formulation under the trade name Aggrenox
b. Both drugs suppress platelet aggregation but do so through different mechanisms.
c. Combination treatment is more effective than either drug alone.
d. Recommended dose is 2 capsules daily—1 in the morning and 1 at night.
e. Significantly more expensive than ASA therapy:approximately $90/month versus $3/month for ASA therapy alone
STROKE/BRAIN ATTACK
I.Definition
A. Rapid onset ofa neurologic deficit involving a certain vascular territory and lasting longer than 24 hours
B. A stroke-in-evolution is an enlarging infarction manifested by neurologic defects that increase over 24 to 48 hours.
C. Stroke is the leading cause ofdisability and the third leading cause ofdeath in the U.S.
D. Stroke can be classified as ischemic and hemorrhagic.
E. 80% ofstrokes are caused by blood clots that produce ischemic areas in the brain;remaining strokes are caused by intracerebral hemorrhage.
II.Etiology and risk factors
A. Same as for TIA
B. Cocaine-related stroke is increasingly common.
C. Women who use oral contraceptives and who smoke are at high risk.
D. Hyperlipidemia raises the risk ofischemic stroke.
E. Low cholesterol increases the risk ofhemorrhagic stroke.
ISCHEMIC STROKE
I.Etiology
A. Caused by a thrombus (30%)
1. Progression ofsymptoms over hours to days
2. Patients often have a history ofTIA.
3. This often occurs during the night while the patient is sleeping;the patient may completely infarct and may be unarousable in the morning.
4. Patient may awaken with a slight neurologic deficit that gradually progresses.
5. Predisposing factors
a. Atherosclerosis
b. HTN
c. DM
d. Arteritis
e. Vasculitis
f. Hypotension
g. Trauma to the head and neck
B. Caused by embolism (25%)
1. Very rapid onset
2. History ofTIA uncommon
3. Patient is usually involved in an activity when symptoms occur.
4. Predisposing factors
a. Atrial fibrillation
b. Mitral stenosis and regurgitation
c. Endocarditis
d. Mitral valve prolapse
II.Clinical manifestations (depend on the cerebral vessel involved)
A. Middle cerebral artery
1. Hemiplegia (involves upper extremity and face more often than lower extremity)
2. Hemianesthesia
3. Hemianopia (blindness ofhalfthe field ofvision)
4. Eyes may deviate to the side ofthe lesion.
5. Aphasia ifdominant hemisphere is involved
6. Occlusions ofvarious branches ofthe middle cerebral artery may cause different findings (involvement ofthe anterior division may cause expressive aphasia,and involvement ofthe posterior branch may produce receptive aphasia).
B. Anterior cerebral artery
1. Hemiplegia (lower extremity more often than upper extremity)
2. Primitive reflexes (such as thumb sucking)
3. Urinary incontinence
4. Bilateral anterior infarction may cause behavioral changes and disturbance in memory.
C. Vertebral and basilar arteries
1. Ipsilateral cranial nerve findings
2. Contralateral (or bilateral) sensory and motor deficits
D. Deep penetrating branches ofmajor cerebral arteries (lacunar infarction)
1. Most common:less than 5 mm in diameter
2. Associated with poorly controlled HTN or diabetes
3. Contralateral pure motor or sensory deficit
4. Ipsilateral ataxia with crural (pertaining to the leg or thigh) paresis
5. Dysarthria with clumsiness ofthe hand
6. Prognosis for recovery is high,with partial or complete resolution occurring over 4 to 6 weeks.
III.Diagnostics/laboratory findings
A. CT scan ofthe head without contrast should be done initially.
1. Preferable to MRI in the acute stage to rule out cerebral hemorrhage when MRI may not easily detect hemorrhage in the first 48 hours (especially when anticoagulation is considered),when signs and symptoms cannot be explained by one lesion,when patient presents with stroke on anticoagulation therapy,and to rule out abscess,tumor, and SDH
2. Appears as an area ofdecreased density
3. Lacunar infarcts appear as small,punched-out,hypodense areas.
4. Initial CT scan may be negative,and the infarct may not be visible for 2 to 3 days after its occurrence.
B. Chest radiography
1. May reveal cardiomegaly or valvular calcification
2. Neoplasm may suggest metastasis rather than stroke as the cause of neurologic deficits.
C. CBC,sedimentation rate,blood glucose,VDRL,lipid profile,INR,PTT prior to anticoagulation,blood urea nitrogen (BUN)/serum creatinine (Cr) to evaluate renal function before contrast media may be given, homocysteine level,drug screen,and blood alcohol level
D. Electrocardiogram (ECG) (ifunrevealing,may place patient on cardiac monitor/Holter monitor)
E. Blood cultures ifendocarditis is suspected
F. Echocardiography
G. TEE to detect dysfunction ofleft atrium (thrombus)
H. Carotid duplex ultrasonography
I. MRI/MRA:Diffusion-weighted MRI is more sensitive than conventional MRI in detecting cerebral ischemia.
J. CT angiography
1. Can provide information regarding vascular anatomy with three-dimensional (3D) reconstruction (requires the use of contact dye)
2. May allow for rapid evaluation and diagnosis in hospitals without MRI capability
