Physical Exam Rewrite

Need rewrite of 1700 word assignment .

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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. The patient said that he developed blurred vision during reading. The patient felt numbness when the pain started (Harriot et al., 2020). The patient 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.

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.

HEENT

No epistaxis, no tinnitus, mild sinus pain, mild ear pain. No oral lesions, gingival bleeding, and dental pain; however, dysphagia and aphasia are present.

Eyes

Visual changes present, headache, eye pain, and blurred vision.

Cardiovascular

Short breathing, loss of consciousness, fainting was present—claudication and palpitations present.

Pulmonary

Hiccups, short breathing, mild cough present.

Gastrointestinal

No abdominal pain, no cramps. However, nausea, vomiting, and difficulty in swallowing present.

Genitourinary

No dysuria, hematuria, nocturia. Vo obvious genitourinary complications observed.

Integumentary

Mild skin rash, no lesions, no wound, no physical trauma, and skin is intact. However, an incisional line is present in the neck region due to neck surgery.

Musculoskeletal

Unilateral numbness of the face, arm, and leg. Muscle weakness, paralysis on the left side, stiffness. Difficulty in movement and maintaining body posture.

Neurological

blurred vision, normal smell sense, normal taste, and hearing. Severe headache, numbness, limb weakness, faintness, and fits present.

Psychiatric

Stress, confusion, anxiety, disturbed sleep patterns, and personality changes.

Endocrine system

Mild overactive adrenal gland and underactive thyroid functions.

5. Vital signs and weight.

Weight

· 154 lbs.

Vital signs

· Temp = 98F, HR = 66bpm, O2= 98%, RR = 1.21, BP = 138/92mmHg.

6. Physical exam with a complete head-to-toe evaluation.

General

The patient looked panicked, confused, and weak.

Eyes

Eye pain and blurred vision.

ENT

Difficulty in swallowing. Abnormal head positioning, nose bleeding not present, mild ear pressure. Normal oral mucosa. No obstruction, no sinus pain. No hoarseness.

NECK

Mild neck stiffness, incisional line on the right side of the neck due to neck surgery. No palpable swelling.

Lymph nodes

No lymphadenopathy

Cardiovascular

Normal cardiac sounds with no noticeable vibrations. No chest pain; however, dyspnea present.

Respiratory

Short breathing, mild cough, dyspnea, and wheezing are present.

Integumentary

No skin rash or bruise, intact warm skin; however, frequent sweats with no erythematous areas.

Neurological

Severe throbbing headache, tremors and ataxia, loss of sensation, memory loss, and slurred speech.

Psychiatric

Stress, anxiety, confusion present. Fear for the ongoing symptoms of the disease was present. Insomnia and depressed mood.

Endocrinal

Loss of appetite, with polyuria and polydipsia.

Genitourinary

No urinary tract infection, no rash, no sexually transmitted disease. However, polyuria is observed.

Gastrointestinal

A normal bowel movement, no constipation, no bloating.

Musculoskeletal

Right arm and leg paresthesia, difficulty in movement, and standing.

Extremities

No edema, clubbing, and cyanosis.

Include pertinent positives and negatives based on findings from the head-to-toe exam.

Positives

· Anorexia

· Polyuria

· Depressive mood swings

· Insomnia

Negatives

· Urinary tract infection

· Edema

· Heartburn

7. Lab/Imaging/Diagnostic test results (including date). (CPT codes).

CBC

· RBC (Code 82482) = 6.4 cells/mcL, Platelet count (Code 85049) = 370,000.

Coagulation tests PT, PTT, INR

· Prothrombin time PT (Code 85610) = 8 secs

· Partial thromboplastin PTT (Code 117796) = 19 secs

· International normalized ratio INR (Code 93793) = .9

Lipid profile (Code 80061)

· Total cholesterol = 190mg/dl

· Non- HDL = 130mg/dl

· LDL = 110mg/dl

· HDL = 55mg/dl

Imaging Diagnostic tests

CT Scan (Code 70460)

The scan shows an ischemic stroke of the middle cerebral artery. A darker, less dense area in the middle cerebral artery is observed.

MRI (Code 70553)

The ischemic lesion is observed in the middle cerebral artery with signs of intravascular thrombus.

Assessment and Clinical Impressions

1. Identify at least three differential diagnoses based upon the chief complaint, ROS, assessment, or abnormal diagnostic tools with rationale. (ICD-10 codes)

· Brain tumor (ICD-10-CM C71)

· Hemorrhagic stroke (ICD-10-CM C161.9)

· Subdural hemorrhage (ICD-10-CM C162)

· Neurosyphilis (ICD-10-CM A52)

· Hypertensive encephalopathy (ICD-10-CM 167.4)

2. Include a complete list of all diagnoses that are both acute and chronic.

· Cerebral Ischemia (ICD-10-CM 167.82)

· Complex or atypical migraine (ICD-10-CM 109)

· Wernicke’s encephalopathy (ICD-10-CM E51.2)

· CNS abscess (ICD-10-CM G06.0)

· Meningitis (ICD-10-CM G03.9)

· Multiple sclerosis (ICD-10-CM G35)

· Transient global amnesia (ICD-10-CM G45.4)

· Cerebral amyloid angiopathy (ICD-10-CM 168)

Rationale

· Brain tumor (ICD-10-CM C71)

The brain tumor is an abnormal growth of brain cells that results in increased intracranial pressure leading to severe headache in the morning, insomnia, and fatigue. The rationale for selecting a brain tumor as the differential diagnosis is the prime symptoms and the relative time of occurrence of these symptoms as the patient felt severe headache with seizures, fatigue, and drowsiness.

· Hemorrhagic stroke (ICD-10-CM C161.9)

When a blood vessel breach and drain blood into the tissue of brain and brain cells begin to die causing the loss of consciousness, severe headache, and seizures. I put hemorrhage stroke on the top of the list of differential diagnosis as the patient displays neck stiffness. Additionally, he has a long history of hypertension.

· Subdural hemorrhage (ICD-10-CM C162)

Subdural hemorrhage manifests bleeding between the brain dura matter due to head injury leading to headache, confusion, slurred speech, and rapid mood swings. The rationale for subdural hemorrhage is to figure out the underlying cause of post-traumatic brain conditions as the patient has neck surgery at the age of 42 and exhibiting the symptoms of dizziness, nausea, and confusion associated with a severe headache.

3. List the differential diagnoses and chronic conditions in order of priority.

I prioritize the differential diagnosis according to the current physical findings.

· Cerebral Ischemia (ICD-10-CM 167.82)
· Hemorrhagic stroke (ICD-10-CM C161.9)
· Subdural hemorrhage (ICD-10-CM C162)
· Brain tumor (ICD-10-CM C71)
· Neurosyphilis (ICD-10-CM A52)
· Hypertensive encephalopathy (ICD-10-CM 167.4)
· Meningitis (ICD-10-CM G03.9)

· CNS Abscess (ICD-10-CM G06.0)

· Transient amnesia (ICD-10-CM G45.4)

· Cerebral amyloid angiopathy (ICD-10-CM 168)

Plan Component Management and Plan Criteria Incorporation

1. Select appropriate diagnostic and therapeutic interventions based on efficacy, safety, cost, and acceptability. Provide a rationale.

The main objective of the treatment intervention is to restore the blood supply to the part of the brain where the block occurs. An emergency IV medication is administered to break up or dissolve the clot (Hawkes et al., 2020). Endovascular therapy in which a thin catheter is inserted through an artery directly approaches the stroke area for urgent blood supply to the affected area. These methods are efficient and cost-effective indeed and ensure the safety of the patient. Moreover, Diagnostic interventions involve pre-and post-procedure CT scans and MRI to assess the location and dissolution of the clot (Muller et al., 2020).

The rationale for treatment interventions

The rationale for this intervention is to restore the blood supply to the stroke area by surgical or non-surgical interventions to secure the life of the patient.

2. Discuss disposition and expected outcomes.

The treatment outcomes are productive, as we will dissolve the clot by IV medication more quickly. Moreover, the catheterization provides successful revascularization of the affected area to restore the brain’s blood supply.

3. Identify and address health education, health promotion, and disease prevention.

Through health education programs, the population would be able to understand the risk factors of cerebral ischemia. Health promotion programs involve using a healthy diet, healthy lifestyle, and cessation of non-healthy habits such as smoking, drinking, and high sugar and fats consumption that lead to blockage of arteries. These programs help in reducing the risk factors, ultimately creating ways for disease prevention.

4. Provide a case summary with ethical, legal, and geriatric considerations. Consider potential issues, even if they are not evident.

Cerebral ischemia is a serious medical condition in which there is little chance of functional recovery. The provision of an advance directive or living Will is necessary for the patient as he can express his feelings about his medical predicament. However, in this condition, the family and health care providers should pursue clinical interventions according to the patient’s safety demands without any delay. Additionally, the will of geriatric patients with cerebral ischemia should be considered before any major clinical intervention.

References

Çelik, Ö., Güner, A., Kalçık, M., Güler, A., Demir, A. R., Demir, Y., … &Ertürk, M. (2020). The predictive value of CHADS2 score for subclinical cerebral ischemia after carotid artery stenting (from the PREVENT‐CAS trial). Catheterization and Cardiovascular Interventions.

De Cock, E., Batens, K., Hemelsoet, D., Boon, P., Oostra, K., & De Herdt, V. (2020). Dysphagia, dysarthria, and aphasia following a first acute ischemic stroke: incidence and associated factors. European Journal of Neurology.

Harriott, A. M., Karakaya, F., &Ayata, C. (2020). Headache after ischemic stroke: A systematic review and meta-analysis. Neurology, 94(1), e75-e86.

Haegens, N. M., Gathier, C. S., Horn, J., Coert, B. A., Verbaan, D., & van den Bergh, W. M. (2018). Induced hypertension in preventing cerebral infarction in delayed cerebral ischemia after subarachnoid hemorrhage. Stroke, 49(11), 2630-2636.

Hawkes, M. A., Hlavnicka, A. A., &Wainsztein, N. A. (2020). Reversible cerebral vasoconstriction syndrome is responsive to intravenous milrinone. Neurocritical Care, 32(1), 348-352.

Muller, S., Dauyey, K., Ruef, A., Lorio, S., Eskandari, A., Schneider, L., … &Kherif, F. (2020). Neuro-Clinical Signatures of Language Impairments after Acute Stroke: A VBQ Analysis of Quantitative Native CT Scans. Current Topics in Medicinal Chemistry, 20(9), 792-799.