advance health assessment week 6- peer review

Instructions:

Please respond to at least 2 of your peer’s posts.  To ensure that your responses are substantive, use at least two of these prompts:

  • Do you agree with your peers’ assessment?
  • Take an opposing view to a peer and present a logical argument supporting an alternate opinion.
  • Share your thoughts on how you support their opinion and explain why.
  • Present new references that support your opinions.

Responses need to address all components of the question, demonstrate critical thinking and analysis, and include peer reviewed journal evidence to support the student’s position.

 

1- Laura Helge-Smith

Neuro Case Study

Subjective:

CC: a 60-year-old man was brought to the ER by ambulance because of slurred speech and left side weakness.

HPI: The patient was brought to the ER by ambulance because of slurred speech and left side weakness. The wife states that they went to bed at 11 pm and awoke at 5 am. This is when she noticed the patient’s symptoms.

PMH: The patient has a history of Coronary Artery Disease, Hypertension, Hypercholesterolemia, and heart attack at age 50. The patient had an episode of blindness in his right eye a month ago that lasted about five minutes. About three months ago his wife states that he had bilateral leg pain while they were on a walk that lasted about fifteen minutes.

Allergies: NKA

Medication: The patient takes a baby aspirin once daily, also an ACE inhibitor and a Statin.

Social History: The patient has a history of alcohol use and smoking in the past but quit after his heart attack.

Family History: Not given

Health Maintenance: Non given

Review of Systems:

General: The patient is a 60-year-old male brought into the ER due to acute onset of slurred speech and left side weakness. The patient was fine when he went to bed, but upon waking at five am, his wife noticed his hypertension and hypercholesteremia. The patient does have a history of alcohol use and tobacco use. The patient had episodes of amaurosis fugue in his right eye about a month ago and bilateral leg pain about three months ago.

HEENT: Right eye blindness for five minutes one month ago.

CV: Hypertension, Coronary Artery Disease, Hypercholesteremia, Heart attack at age 50

MSK: No movement in left arm and left leg. Bilateral leg pain 3 months ago that lasted about 15 minutes.

Neuro: Slurred Speech

Objective:

General: 60-year-old male presenting to the ER with slurred speech and left side weakness upon waking this morning.

VS: BP 195/118, Pulse 106, Respirations 18, Temperature 99.8, O2 saturation 97% on Room Air

HEENT: Patients pupils are Equal and Reactive to light, and ocular movements are intact. The patient is unable to turn his eyes voluntarily toward the left side.

Neck: The patient’s neck is supple, there is no jugular vein distension, and there are no bruits.

CV: Heart sounds are regular, no murmurs

Lungs: Clear

Abdomen: Normal

PV: The limbs are not well perfused distally

MSK: The patient is unable to move his left arm and leg, has hyperreflexia, and the left great toe is upgoing.

Neuro: The patient is alert and oriented, although he does not recognize that he is sick, this is called left neglect and is common in victims of right-side stroke. He shows a 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 noted mild weakness on the left side of the face and left-sided homonymous hemianopsia, but there is no nystagmus or ptosis, and no tongue or uvula deviation.

The two questions that I would ask this patient would be, are you taking your medications every day as prescribed? The patient’s blood pressure is extremely high and is not well controlled for a person on hypertensive therapy. Another question that I would ask this patient is if he has experienced any headaches or dizziness before this episode. The patient’s pain in his legs and the short episode of blindness in his right eye are both precursors to stroke.

Social determinants of health for this patient would be possible noncompliance with medications, and the patient’s past alcohol and tobacco use, because smokers and drinkers are significantly associated with early death (Zhang et al. 2021).

 

2- Alexander Olson

Two Questions

It is important to determine an individual’s risk factors in this type of situation. A few risk factors are already present for stroke such as hypertension, imbalance of cholesterol, and a history of smoking. The first question I would ask is if the patient has any family history of stroke/cerebrovascular accident or transient ischemic attack. Research suggests that family history is one of the main risk factors for stroke (Pourasgari et al., 2020). The second question I would ask this patient is if they woke up at all in the middle of the night experiencing any symptoms. Unfortunately, wake-up strokes account for approximately 20% of all strokes (Peter-Derex et al., 2019). This occurs when an individual falls asleep feeling fine but wakes up experiencing symptoms. It is noted that the wife first noticed that the husband was having symptoms when they woke up at around 6am. However, if the patient woke up at any point in the middle of the night feeling either fine or symptomatic, this would provide a more accurate window of onset of symptoms. This could be the difference of whether the patient may be a candidate for alteplase/TPA, the gold standard for thrombotic stroke, which may only be given 4.5 hours within the onset of stroke symptoms (Pena et al., 2017).

 

Subjective Data

Chief Complaint: Slurred Speech and Left Side Weakness

History of Present Illness:

This 60-year-old male presents to the office at this date for an evaluation of slurred speech and left side weakness. Per patient’s wife, they went to bed at approximately 11pm and woke up at 5am. She then noticed his symptoms. Patient has a medical history of hypertension on an ACE inhibitor, hypercholesterolemia on a statin, coronary artery disease on aspirin, and heart attack 10 years ago (2012). Recent history includes an episode of amaurosis/blindness in the right eye which lasted approximately 5 minutes one month ago, and bilateral leg pain which lasted approximately 15 minutes three minutes ago. Current symptoms include slurred speech and inability to move left arm and leg.

Past Medical History:

Hypertension on ACE inhibitor. Year diagnosed/followed by/last appt not provided.

Hypercholesterolemia on statin. Year diagnosed/followed by/last appt not provided.

Coronary Artery Syndrome on aspirin. Year diagnosed/followed by/last appt not provided.

Heart Attack – 2012.

Prior hospitalizations/surgeries not provided.

Allergies: Not provided.

Medications:

Ace Inhibitor – specific med/ dose/ frequency/ last taken not provided.

Statin – specific med/ dose/ frequency/ last taken not provided.

Aspirin – dose/ frequency/ last taken not provided.

Social History:

Married. Admits to smoking and drinking in the past but stopped after his heart attack. Type and amount not provided. Children/sexual activity/ education/employment status/financial status/living situation/diet/exercise not provided.

Family History: Not provided.

Health Maintenance/Promotion: Not provided.

Review of Systems:

General: Endorses weakness.

Skin/Hair/Nails: Not provided.

Neurological: Endorses weakness.

HEENT: Endorses slurred speech.

Neck: Not provided.

Cardiovascular: Not provided.

Peripheral Vascular: Not provided.

Lungs: Not provided.

Gastrointestinal: Not provided.

Genitourinary: Not provided.

Musculoskeletal: Endorses left side weakness.

Endocrine: Not provided.

Psychiatry: Not provided.

 

Objective Data

Ht: —/ Wt: —/ BMI: — (Interpretation: —)

Vitals: BP 195/118, HR 106, RR 18, Temp 99.8, O2sat 97% on RA

General: Understands and follows commands.

Skin/Hair/Nails: Not provided.

Neurological: Alert and oriented. Does not recognize he is sick. Loss of awareness and attention with respect to objects or stimuli on left side.

HEENT: Pupils equal and reactive. Ocular movements intact. Unable to turn eyes voluntarily toward the left side. Mild dysarthria. Speech is fluent. Able to Understand and follow commands very well. Mild weakness on the left side of the face. Left sided homonymous hemaianopsia. No nystagmus or ptosis, and no tongue or uvula deviation.

Neck: Supple, no jugular venous distension, no bruits.

Cardiovascular: Regular without murmurs.

Peripheral Vascular: Not well perfused distally

Lungs: Breath sounds are clear bilaterally.

Gastrointestinal: Abdomen normal.

Genitourinary: Not provided.

Musculoskeletal: Left sided weakness. Unable to move left arm and leg. Hyperreflexia. Left greater toe is upgoing.

Endocrine: Not provided.

Psychiatry: Not provided.

Labs: Not provided.

Imaging: Not provided.

 

 

Social Determinants of Health

Research suggests that approximately half of stroke-related deaths have a social determinants of health (SDOH) aspect; specially, socioeconomic status and available of resources related to the management of modifiable risk factors (Avan et al., 2019). It is not provided whether this patient pursued medical attention after his episode of right sided blindness or after his incident of bilateral leg pain. When he arrived at the office, his blood pressure was in hypertensive crisis range – 195/118 – despite being on ACE inhibitors. It is important to determine if the patient has the economic and financial means to afford his medications, make follow-up appointments with his provider to change or add on new medications if needed, make appointments for medical episodes and events such as what occurred one month ago and three months ago. The patient could have experienced the bilateral leg pain due to a DVT, which dislodged to cause this event. If the patient had been able to receive adequate care at the time when he was experiencing that pain, this could have been avoided.

 

 

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