Academic Clinical History and Physical Note 2 (Hemorrhagic Stroke)

Academic Clinical History and Physical Note 2

Chief Complaint or Reason for Consult: “Left-sided weakness.”

History of Present Illness (HPI): N.P. is a 78-year-old AA male brought to the ED by the paramedical team in the company of his wife. The patient’s wife reports that the patient suddenly developed left-sided weakness and could not lift objects with his left head or move his left leg. The left side of his face also became weak, and his vision declined drastically. On noting this, she asked the husband how he felt, but he denied his problems. His level of consciousness started deteriorating and the wife feared that he would get into a coma if he was not rushed to the ED. Before the ambulance arrived, the patient complained of a headache and had one episode of vomiting.

Past Medical History: History of HTN; Diagnosed at 76 years. He has had a history of obesity since his 40s.

Hyperlipidemia diagnosed at 65 years; Managed with Simvastatin 40 mg QHS.

Past Surgical History: None.

Family History: The father had CA liver and died at 84 years. His mother died from pneumonia at 87 yea

rs. His paternal grandfather had HTN and died from a stroke. His younger brother, 72 years, has prostate cancer. Children are alive and well.

Social History: N.P. lives with his wife in their countryside home. He is a retired telecommunications manager and studied up to the Graduate level. He has a history of alcohol intake and smoking 1-2 PPD but stopped two years ago after being diagnosed with HTN. His hobbies include watching TV and playing chess. He states that he walks around his farm for 15-20 minutes every morning and evening as exercise.

Allergies: No food or drug allergies.

Home Medications: None

Hospital Medications: HCTZ 25 mg OD; Enalapril 20 mg/day; Simvastatin 40 mg QHS.

Review of Systems:

CONSTITUTIONAL: Left-sided weakness. Denies chills, fever, or weight changes.
EYES: Neglect the left visual field. Denies eye pain or excessive tearing.
EARS, NOSE, and THROAT: Positive for right-sided facial weakness. Denies tinnitus, ear discharge, sneezing, rhinorrhea, throat pain, hoarse voice, or bleeding gums.
CARDIOVASCULAR: Denies SOB, chest tightness, palpitations, or edema.
RESPIRATORY: Denies SOB, cough, chest tightness, sputum production, or wheezing.
GASTROINTESTINAL: Reports nausea and vomiting. Denies abdominal pain, tarry stools, or bowel changes.
GENITOURINARY: Denies dysuria, penile discharge, increased urination, or urinary urgency or frequency.
MUSCULOSKELETAL: Reports limitations in movement. Denies joint/ muscle pain or stiffness.
INTEGUMENTARY: Denies skin rashes, itching, bruises, or lacerations.
NEUROLOGICAL: Positive for headache, left-sided paralysis, and gait disturbance.
PSYCHIATRIC: Denies anxiety or depressive symptoms.
ENDOCRINE: Denies heat/cold intolerance, acute thirst, or hunger.
HEMATOLOGIC/LYMPHATIC: Denies bleeding, bruising, or lymph node enlargement.
ALLERGIC/IMMUNOLOGIC: Negative for hives or allergies.

Physical Exam:

GENERAL APPEARANCE: The patient is a 78-year-old AA male. He is disoriented to time, place, and person and is unaware of neurologic deficits. He is neat and appropriately dressed for the function and weather.
VITAL SIGNS: BP- 188/118; HR- 102; RR-20; Temp: 98.42 F; Sp02-97; Wt-220; Ht-5’5; BMI- 36.6
HEENT: Head: Normocephalic and symmetrical. Eyes: Sclera is white and conjunctiva pink; Right gaze preference; Left visual field cut; Abnormal left eye movement. Ears: Tympanic membranes are shiny and intact; Reduced ability to hear a tonal variation. Nose: No nasal secretions or bleeding; The nasal septum is well-aligned. Mouth & Throat: Pink and moist mucous membranes; Tonsillar glands are non-erythematous.
NECK: Limited neck ROM. The trachea is midline and well-aligned.
CHEST: Symmetric; Uniform respirations. Non-tender to palpation
LUNGS: Lungs clear bilaterally.
HEART: No edema or neck vein distention; Regular heart rate and rhythm.
BREASTS: Non-tender with no masses.
ABDOMEN: Abdomen is soft; Normoactive BS in all quadrants. No epigastric or abdominal tenderness or organomegaly.
GENITOURINARY: No penile discharge or scrotal swelling.
RECTAL: Normal sphincter tone. No rectal fissures or ulcerations. The prostate is smooth and non-tender.
EXTREMITIES: Altered muscle tone and reflexes in left upper and lower limbs.
NEUROLOGIC: Ataxic gait; dysarthria; left facial, arm, and leg paresis.
PSYCHIATRIC: Short attention span; Impaired judgment.
SKIN: Warm and dry, fair skin with no rashes or lesions.
LYMPHATICS: Lymph nodes are non-palpable.

Laboratory and Radiology Results:

Noncontrast right Brain CT scan- Acute hemorrhage in the right gangliocapsular region,

Differential Diagnosis:

Hemorrhagic Stroke: It results from bleeding into the brain tissue or the subarachnoid space or ventricles. The clinical manifestations of hemorrhagic stroke are usually acute and progressing. Common features include acute onset headache, neck stiffness, vomiting, increases in blood pressure, and rapidly developing neurological signs (Montaño et al., 2021). The patient had an acute onset of neurological deficits with altered consciousness, headache, and vomiting, making this a possible diagnosis.

Ischemic Stroke: This is caused by inadequate blood flow to the brain from partial or complete occlusion of an artery. Clinical manifestations include subjective arm and leg weakness and paresthesia, speech disturbance, facial weakness, headache, dizziness, dysarthria, and visual defect (Chugh, 2019). The patient presents with these features making Ischemic stroke a differential diagnosis. However, acute onset of neurologic deficit, altered level of consciousness or mental status, and coma are more common with hemorrhagic stroke than with ischemic stroke.

Acute hypertensive emergency: This is an acute, marked increase in blood pressure linked with signs of target-organ damage. Patients who present with headaches, altered mental status, dizziness, chest pain, shortness of breath, vision changes, vomiting, or reduced urine output, necessitate further evaluation (Pierin et al., 2019). The patient has a BP of 188/118, making Acute hypertensive emergency a differential diagnosis.

Acute and Chronic Medical Conditions:

Hemorrhagic stroke

Hypertension

Obesity

Treatment Plan:

Medications:

Initially, Labetalol 20 mg IV over 2 minutes, then as a continuous infusion at 2 mg/min.

Hydralazine 20 mg IV.

Switch Enalapril from oral IV to 1.25 mg/dose over 5 minutes QID.

Continue HCTZ 25 mg OD

Continue Simvastatin 40 mg QHS.

Health Education:

The patient and family members will be educated about stroke symptoms, including recognizing them and the need for urgent evaluation.

Health education on self-management of hypertension to promote BP control. The patient will be taught measures to control BP, like dietary practices such as the DASH diet, increasing physical activity, reducing alcohol intake, and adhering to medication.

Consultations: An emergent neurosurgical or neurologic consultation in the ED.

Follow-up: A follow-up visit will be scheduled two weeks after discharge to assess the patient’s status and assess for HTN complications.

Geriatric Considerations:

Stroke is a common cause of mortality and disability in geriatrics aged 80 years and above. The major causes of hemorrhagic stroke in geriatric are cerebral amyloid angiopathy and anticoagulant-related hemorrhagic stroke. Preventing or delaying hemorrhagic stroke in geriatric patients with hypertension is crucial in reducing morbidity and increasing healthy life expectancy (Lindley, 2018). As medical problems build up and physiological systems degenerate, geriatrics increasingly present with a syndromic presentation instead of classical stroke symptoms. Thus, they are likely to present with pain, delirium, immobility, falls, incontinence, shortness of breath, and sepsis. Risk factors for hemorrhagic stroke vary in the elderly (>70 years) compared with younger subjects (<70 years) (Lindley, 2018). Hypertension is one of the demonstrable risk factors for hemorrhagic stroke in younger adults but not in older adults. Atrial fibrillation is a risk factor for stroke for persons above 70 years, while left ventricular hypertrophy and smoking are risk factors only for those below 70 years. Thus, the clinician should consider these risk factors when diagnosing geriatrics with a clinical impression of stroke.

References

Chugh, C. (2019). Acute Ischemic Stroke: Management Approach. Indian Journal of critical care medicine: peer-reviewed, official publication of Indian Society of Critical Care Medicine, 23(Suppl 2), S140–S146. https://doi.org/10.5005/jp-journals-10071-23192

Lindley, R. I. (2018). Stroke prevention in the very elderly. Stroke, 49(3), 796–802. https://doi.org/10.1161/STROKEAHA.117.017952

Montaño, A., Hanley, D. F., & Hemphill, J. C., 3rd (2021). Hemorrhagic stroke. Handbook of clinical neurology, 176, 229–248. https://doi.org/10.1016/B978-0-444-64034-5.00019-5

Pierin, A. M. G., Flórido, C. F., & Santos, J. D. (2019). Hypertensive crisis: clinical characteristics of patients with hypertensive urgency, emergency, and pseudocrisis at a public emergency department. Einstein (Sao Paulo, Brazil), 17(4), eAO4685. https://doi.org/10.31744/einstein_journal/2019AO4685

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