A 60-year-old man is brought to the ER by ambulance because of slurred speech and left side weakness. His wife states they went to bed at 11pm and woke up at 5am when she noticed his symptoms. He is right-handed with a history of coronary artery disease, hypertension, and hypercholesterolemia and a heart attack at age 50.
• He currently is unable to move his left arm and leg.
• 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.
• He is taking a baby aspirin a day an ACE inhibitor, and statin as well.
• He does have a history of alcohol use and smoking in the past but stopped after his heart attack.
• His blood pressure is 195/118 Pulse 106, Respiratory rate 18, Temperature 99.8, O2 sat is 97% on room air.
• Although his pupils are equal and reactive, and the ocular movements are intact, he is unable to turn his eyes voluntarily toward the left side.
• The neck is supple, there is no jugular vein distension, and there are no bruits.
• The lungs are clear heart sounds regular without murmurs, and abdomen is normal.
• The limbs are not well perfused distally.
• The neurologic examination reveals that he is alert and oriented, although he does not recognize he is sick.
• He 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.
• He is not able to move his left arm and leg, has hyperreflexia, and the left great toe is upgoing.
After reading the case scenario, please respond to the following questions:
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o What are two questions you would ask this patient?
o Identify the subjective data for this patient.
o Identify the objective data for this patient.
o What Social Determinants of Health would be relevant for this patient?
"Are you having any pain right now, anywhere in your head or neck?" (To screen for potential hemorrhagic conversion, dissection, or associated vascular event).
2. Subjective Data
Subjective data are information gathered from the patient's perspective, family history, and reported symptoms.
Chief Complaint (as reported by wife): Slurred speech and left-side weakness.
Time of Onset: Woke up at 5 AM when symptoms were noticed. Time Last Known Well (LKW) was 11 PM (when they went to bed).
Past Symptoms:
Episode of amaurosis fugax (blindness) in his right eye one month ago, lasting 5 minutes.
Bilateral leg pain while walking (claudication-like symptoms) around three months ago, lasting 15 minutes.
Past Medical History (Reported): Coronary Artery Disease (CAD), Hypertension (HTN), Hypercholesterolemia, and a heart attack at age 50.
Medications (Reported): Baby aspirin, ACE inhibitor, and statin.
Social History (Reported): History of alcohol use and smoking, stopped after his heart attack.
3. Objective Data
Objective data are measurable and observable facts gathered from physical assessment, vital signs, and diagnostic testing.
Vital Signs:
Blood Pressure: 195/118 (Hypertensive Urgency/Emergency level)
Pulse: 106 (Tachycardic)
Temperature: 99.8 (Mildly elevated/Febrile)
O2 Saturation: 97% on room air
General Appearance/Awareness: Alert and oriented. Does not recognize he is sick (Anosognosia).
Neurological Examination (Specific Deficits):
Motor: Left arm and leg are immobile (0/5 strength/plegia).
Sensation/Awareness: Loss of awareness and attention to objects/stimuli on his left side (Left-sided neglect).
Speech/Language: Mild dysarthria (slurred speech). Speech is fluent; comprehension intact.
Cranial Nerves: Mild weakness on the left side of the face. Unable to turn eyes voluntarily toward the left side (Gaze preference).
Visual Fields: Left sided homonymous hemianopsia (loss of vision in the left field of both eyes).
Sample Answer
This patient is presenting with acute neurological deficits highly suggestive of a stroke (CVA), likely involving the right cerebral hemisphere.
Patient Analysis and Data
1. Two Questions You Would Ask This Patient
Given the acute stroke presentation, the most critical question is to establish the Time Last Known Well (LKW) to determine eligibility for thrombolytic therapy (tPA). The second question would focus on current symptoms to assess stability.
"Can you tell me the exact time you last felt completely normal before you went to sleep?" (This is to confirm the 11 PM time LKW, as the window for stroke intervention is time-dependent).