Academic Clinical History and Physical Note 2 (Hemorrhagic Stroke)

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

Academic Clinical History and Physical Note 2 Hemorrhagic Stroke

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



Treatment Plan:


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.



Chugh, C. (2019). Acute Ischemic Stroke: Management Approach. Indian Journal of critical care medicine: peer-reviewed, official publication of Indian Society of Critical Care Medicine23(Suppl 2), S140–S146.

Lindley, R. I. (2018). Stroke prevention in the very elderly. Stroke49(3), 796–802.

Montaño, A., Hanley, D. F., & Hemphill, J. C., 3rd (2021). Hemorrhagic stroke. Handbook of clinical neurology176, 229–248.

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.




Click here to ORDER an A++ paper from our Verified MASTERS and DOCTORATE WRITERS: Academic Clinical History and Physical Note 2 (Hemorrhagic Stroke)


Lopes Write Policy

For assignments that need to be submitted to Lopes Write, please be sure you have received your report and Similarity Index (SI) percentage BEFORE you do a “final submit” to me.

Once you have received your report, please review it. This report will show you grammatical, punctuation, and spelling errors that can easily be fixed. Take the extra few minutes to review instead of getting counted off for these mistakes.

Review your similarities. Did you forget to cite something? Did you not paraphrase well enough? Is your paper made up of someone else’s thoughts more than your own?

Visit the Writing Center in the Student Success Center, under the Resources tab in LoudCloud for tips on improving your paper and SI score.

Late Policy

The university’s policy on late assignments is 10% penalty PER DAY LATE. This also applies to late DQ replies.

Please communicate with me if you anticipate having to submit an assignment late. I am happy to be flexible, with advance notice. We may be able to work out an extension based on extenuating circumstances.

If you do not communicate with me before submitting an assignment late, the GCU late policy will be in effect.

I do not accept assignments that are two or more weeks late unless we have worked out an extension.

As per policy, no assignments are accepted after the last day of class. Any assignment submitted after midnight on the last day of class will not be accepted for grading.


Communication is so very important. There are multiple ways to communicate with me:

Questions to Instructor Forum: This is a great place to ask course content or assignment questions. If you have a question, there is a good chance one of your peers does as well. This is a public forum for the class.

Individual Forum: This is a private forum to ask me questions or send me messages. This will be checked at least once every 24 hours.

Important information for writing discussion questions and participation

Welcome to class

Hello class and welcome to the class and I will be your instructor for this course. This is a -week course and requires a lot of time commitment, organization, and a high level of dedication. Please use the class syllabus to guide you through all the assignments required for the course. I have also attached the classroom policies to this announcement to know your expectations for this course. Please review this document carefully and ask me any questions if you do. You could email me at any time or send me a message via the “message” icon in halo if you need to contact me. I check my email regularly, so you should get a response within 24 hours. If you have not heard from me within 24 hours and need to contact me urgently, please send a follow up text to

I strongly encourage that you do not wait until the very last minute to complete your assignments. Your assignments in weeks 4 and 5 require early planning as you would need to present a teaching plan and interview a community health provider. I advise you look at the requirements for these assignments at the beginning of the course and plan accordingly. I have posted the YouTube link that explains all the class assignments in detail. It is required that you watch this 32-minute video as the assignments from week 3 through 5 require that you follow the instructions to the letter to succeed. Failure to complete these assignments according to instructions might lead to a zero. After watching the video, please schedule a one-on-one with me to discuss your topic for your project by the second week of class. Use this link to schedule a 15-minute session. Please, call me at the time of your appointment on my number. Please note that I will NOT call you.

Please, be advised I do NOT accept any assignments by email. If you are having technical issues with uploading an assignment, contact the technical department and inform me of the issue. If you have any issues that would prevent you from getting your assignments to me by the deadline, please inform me to request a possible extension. Note that working fulltime or overtime is no excuse for late assignments. There is a 5%-point deduction for every day your assignment is late. This only applies to approved extensions. Late assignments will not be accepted.

If you think you would be needing accommodations due to any reasons, please contact the appropriate department to request accommodations.

Plagiarism is highly prohibited. Please ensure you are citing your sources correctly using APA 7th edition. All assignments including discussion posts should be formatted in APA with the appropriate spacing, font, margin, and indents. Any papers not well formatted would be returned back to you, hence, I advise you review APA formatting style. I have attached a sample paper in APA format and will also post sample discussion responses in subsequent announcements.

Your initial discussion post should be a minimum of 200 words and response posts should be a minimum of 150 words. Be advised that I grade based on quality and not necessarily the number of words you post. A minimum of TWO references should be used for your initial post. For your response post, you do not need references as personal experiences would count as response posts. If you however cite anything from the literature for your response post, it is required that you cite your reference. You should include a minimum of THREE references for papers in this course. Please note that references should be no more than 5 years old except recommended as a resource for the class. Furthermore, for each discussion board question, you need ONE initial substantive response and TWO substantive responses to either your classmates or your instructor for a total of THREE responses. There are TWO discussion questions each week, hence, you need a total minimum of SIX discussion posts for each week. I usually post a discussion question each week. You could also respond to these as it would count towards your required SIX discussion posts for the week.

I understand this is a lot of information to cover in 5 weeks, however, the Bible says in Philippians 4:13 that we can do all things through Christ that strengthens us. Even in times like this, we are encouraged by God’s word that we have that ability in us to succeed with His strength. I pray that each and every one of you receives strength for this course and life generally as we navigate through this pandemic that is shaking our world today. Relax and enjoy the course!

Hi Class,

Please read through the following information on writing a Discussion question response and participation posts.

Contact me if you have any questions.

Important information on Writing a Discussion Question

  • Your response needs to be a minimum of 150 words (not including your list of references)
  • There needs to be at least TWO references with ONE being a peer reviewed professional journal article.
  • Include in-text citations in your response
  • Do not include quotes—instead summarize and paraphrase the information
  • Follow APA-7th edition
  • Points will be deducted if the above is not followed

Participation –replies to your classmates or instructor

  • A minimum of 6 responses per week, on at least 3 days of the week.
  • Each response needs at least ONE reference with citations—best if it is a peer reviewed journal article
  • Each response needs to be at least 75 words in length (does not include your list of references)
  • Responses need to be substantive by bringing information to the discussion or further enhance the discussion. Responses of “I agree” or “great post” does not count for the word count.
  • Follow APA 7th edition
  • Points will be deducted if the above is not followed
  • Remember to use and follow APA-7th edition for all weekly assignments, discussion questions, and participation points.
  • Here are some helpful links
  • Student paper example
  • Citing Sources
  • The Writing Center is a great resource