Subjective
The patient reports slurred speech and weakness on the left side that began at 11 p.m. He had a 5-minute episode of amaurosis fugux (blindness) in his right eye about a month ago. His wife claims he had bilateral pain in his legs about 3 months ago while they were on a walk that lasted about 15 minutes. The patient has a history of alcohol use and smoking in the past but stopped after his heart attack.
Objective
The reading is 195/118. Pulse rate of 106, respiratory rate of 18, Temperature is 99.8, O2 saturation is 97% on room air, he is 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 are regular without murmurs, and abdomen is normal, limbs are not well perfused dis The patient exhibits a loss of awareness and attention to objects or stimuli on his left side. He has mild dysarthria, but his speech is clear and he understands and follows instructions well. There is mild weakness on the left side of the face and homonymous hemaianopsia on the left side, but no nystagmus or ptosis, and no tongue or uvula deviation; the patient is unable to move his left arm and leg, has hyperreflexia, and the left great toe is upgoing.
Questions I would ask this patient if he has a history of CVAs, as the patient is presenting with stroke-like signs and symptoms. However, determining whether or not the patient suffers from severe headaches can reveal underlying conditions. The progression of a patient’s symptoms can reveal pathophysiology. A sudden onset of difficulty speaking, for example, may indicate a stroke, whereas a gradual deterioration of speech over a few months may indicate a brain tumor ( Bickley, 2021). I’d also inquire if the patient had recently fallen and hit his head. Damage to upper motor neurons or their projections (the corticospinal tract) can cause weakness, as can damage to lower motor neurons or their projections ( Bickley, 2021). Drinking, smoking, poor diet, lack of exercise and activity, noncompliance with medications, and failure to follow up with a provider and monitor health are all examples of social determinants of health.
