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Neurologic System Patient Case
Patient Case- you should embellish and add additional details to the patient case as needed to reflect full documentation of a musculoskeletal problem, but please use the following basic information to document about your patient:
Subjective Data (history):
Mr. Green, a 52-year-old native Alaskan man
Currently living in long term care
Past medical history: hypertension, smoking, and history of stroke 2 years ago (still has lasting neuro side-effects from this, left sided weakness)
Allergies: aspirin
HPI: Patient currently has a headache. He describes as severe (10/10), pounding/throbbing headache that had been present for “a few hours.” He also has blurry vision– ask him PQRSTU about his headache symptoms and his vision
Physical Exam (Objective)
Vital Signs: Oral Temp 36.8 C, HR 88 BPM, RR 22, and BP 168/92 mm Hg
Inspection: Alert but confused: Oriented to person and place only. Speech is slightly slurred. CN II impaired on Snellen test. CN VII impaired, left lower facial droop present. All other CN should be documented as intact.
Palpation: Muscle strength 2/5 left arm – 3/5 left leg. All other neuro assessments should be documented as intact/expected/normal.
Actual or Potential Risk factors
- Green is at risk for… because the assessment findings indicate that…
- Green is also at risk for…because the assessment findings indicate…
Neurologic System Patient Case
Patient Case- you should embellish and add additional details to the patient case as needed to reflect full documentation of a musculoskeletal problem, but please use the following basic information to document about your patient:
Subjective Data (history):
Mr. Green, a 52-year-old native Alaskan man
Currently living in long term care
Past medical history: hypertension, smoking, and history of stroke 2 years ago (still has lasting neuro side-effects from this, left sided weakness)
Allergies: aspirin
HPI: Patient currently has a headache. He describes as severe (10/10), pounding/throbbing headache that had been present for “a few hours.” He also has blurry vision– ask him PQRSTU about his headache symptoms and his vision
Physical Exam (Objective)
Vital Signs: Oral Temp 36.8 C, HR 88 BPM, RR 22, and BP 168/92 mm Hg
Inspection: Alert but confused: Oriented to person and place only. Speech is slightly slurred. CN II impaired on Snellen test. CN VII impaired, left lower facial droop present. All other CN should be documented as intact.
Palpation: Muscle strength 2/5 left arm – 3/5 left leg. All other neuro assessments should be documented as intact/expected/normal.
Actual or Potential Risk factors
- Green is at risk for… because the assessment findings indicate that…
- Green is also at risk for…because the assessment findings indicate…