Subjective
The patient reports slurred speech and left side weakness onset 11 pm. He had an episode of amaurosis fugux (blindness)in his right eye one month ago that lasted for 5 minutes. Around 3 months ago his wife states he had bilateral pain in his legs while they were on a walk that lasted about 15 minutes, the patient reports a history of alcohol use and smoking in the past but stopped after his heart attack.
Objective
Blood pressure is 195/118 Pulse 106, Respiratory rate 18, Temperature 99.8, O2 sat is 97% on room air, unable to move his left arm and leg, pupils are equal and reactive, and the ocular movements are intact, he is unable to turn his eyes voluntarily toward the left side, neck is supple, there is no jugular vein distension, and there are no bruits, lungs are clear heart sounds regular without murmurs, and abdomen is normal, limbs are not well perfused distally, neurologic examination reveals that he is alert and oriented, although he does not recognize he is sick. The patient shows loss of awareness and attention with respect to objects or stimuli on his left side. He has mild dysarthria but, his speech is fluent, and he understands and follows commands very well. There is mild weakness on the left side of the face and left sided homonymous hemaianopsia, but there is no nystagmus or ptosis, and no tongue or uvula deviation, the patient is not able to move his left arm and leg, has hyperreflexia, and the left great toe is upgoing.
Questions that I would ask this patient, if he has had a history of CVAs, the way that the patient is presenting is with signs and symptoms of a stroke. Although assessing if the patient get really bad headaches can also indicate underlying conditions. The time course of a patient’s symptoms can provide clues to the pathophysiology. The sudden onset of difficulty speaking, for example, may suggest a stroke whereas a progressive worsening of speech over a few months may suggest a brain tumor ( Bickley, 2021). I would also ask if the patient had any recent falls and hit his head. Weakness can be caused by damage to upper motor neurons or their projections (the corticospinal tract) or by damage to lower motor neurons or their projections ( Bickley, 2021). Social determinants to health would be drinking, smoking, poor diet, lack of exercise and activity, not complying with meds and not following up with a provider and monitoring health.
