Academic Clinical History & Physical Notes for Cerebral Ischemia

Academic Clinical History & Physical Notes for Cerebral Ischemia

I am presenting the academic clinical history and physical notes for the patient of ischemic stroke. Ischemic stroke or cerebral ischemia occurs when one of the cerebral arteries is blocked by the clot leading to diminished blood supply and oxygen to brain cells resulting in damage or death of brain cells (Celik et al., 2020)

History and Physical Note

1. Chief complaint/reason for admission/visit/consult.

A 52 years old male patient came to the acute care hospital with the chief complaint of sudden severe headache, dizziness, and slurred speech.

HPI for the H&P or consult notes.

The patient felt a severe burning and shooting pain in the frontal region of the head while he was reading the newspaper in the morning, said that he developed blurred vision during readin, felt numbness when the pain started (Harriot et al., 2020) and said that the pain was not subsiding with the time as it persisted since its onset. The pain scale was nine by 10, started in the frontal region, and radiated towards the temporal region.

The associated symptoms with pain are nausea, vomiting, aphasia, dysarthria, apraxia, and vertigo (De Cock, et al., 2020). The symptoms become aggravate in a standing position and become alleviating when he lay down on the bed with 3 pillows. The patient felt a significant change in body posture. He is positive for facial drooping while negative for fever and chills. He finds difficulty in sitting and maintaining coordination. The patient stated that he had a medical history of neck trauma in a road accident. He was hospitalized for 3 weeks after neck surgery.

Academic Clinical History & Physical Notes for Cerebral Ischemia

2. Medical, surgical, family, social, and allergy history.

Medical history

The patient has hypertension and hypercholesterolemia (Haegens, et al., 2018).

Surgical history

The patient underwent neck surgery after neck trauma at the age of 42.

Family history

The patient’s mother is alive and diabetic. The father of the patient died due to a cardiac stroke. His sister is normal. One of the two brothers has hypertension, and the other is normal. Currently, the patient is living with his normal wife.

Social history

The patient has a long history of smoking and boozing, coupled with a sedentary lifestyle.

Allergy history

· Raw fruits and vegetables, Shellfish, Soy.

· Amoxicillin and aspirin.

3. Home medications, including dosages, route, frequency, and current medications, if a consultation note.

Antihypertensive drugs Edarbi & Hygroton.

40 mg oral Edarbi once a day, as the patient is on diuretics, Hygroton. Oral 50 mg Hygroton once in the morning.

Hypercholesterolemic drugs Lipitor

Oral tablet 40 mg once a day. He takes this tablet at night.

4. Review of systems with all body systems for H&P or consult notes. Review of systems is what the patient or family/friends tell you (by body system).

General appearance

The patient shows facial weakness, numbness, confusion, sweating, and dizziness. Facial drooping present.

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