Skip to Main Content

++

Examination

++

History

++

  • Demographic Information:

    The patient is a 55-year-old African American man presenting to inpatient rehabilitation status post left basal ganglia hemorrhage with right hemiparesis.

  • Medical History:

    The patient has a medical history significant for hypertension, hyperlipidemia, and chronic renal insufficiency.

  • History of Present Illness:

    The patient presented to the emergency room 1 week ago with a complaint of right-sided weakness and was noted to be hypertensive. During his acute hospital stay, he was found to be positive for right posterior tibial deep vein thrombosis (DVT), with resultant inferior vena cava (IVC) filter placement. His acute hospital course was otherwise uncomplicated, and he was transferred to inpatient rehabilitation to address the chief complaints of gait and balance deficits and difficulties with activities of daily living (ADL).

  • Diagnostic and Laboratory Findings:

    • A computed axial tomography (CAT) scan of the brain revealed left basal ganglia hemorrhage with minimal mass effect (midline displacement) and no intraventricular hemorrhage. Magnetic resonance imaging (MRI) showed a 0.59-in. (1.5-cm) intracranial hemorrhage in the left basal ganglia region, left lateral thalamus, and left internal capsule. No neurosurgical intervention was recommended (the IVC filter was placed, as anticoagulation was contraindicated).

    • White blood cell count = 5.2, hemoglobin = 11.4, hematocrit = 34.7, platelets = 221.

  • Medications:

    • Prior to admission: Zocor, Coreg, Lopressor

    • Admission medications: Labetalol, hydrochlorothiazide, Lotrel, Nexium, Singulair, Ambien

  • Social History:

    Prior to admission, the patient was independent in ambulation without an assistive device and independent in all ADL. He lived alone in a two-level house with three steps to enter with one right-side railing. Inside the home, 12 steps lead to the second floor with a right-side railing, where the bedroom and bathroom are located. Both of his parents are alive and healthy, and the patient denies a family history of diabetes, hypertension, or stroke. The patient denies tobacco use and notes minimal use of alcohol for social occasions.

  • Employment:

    Patient was employed full time as a registered nurse in a rehabilitation hospital, working a 12-hour overnight shift 3 or 4 days per week.

++

Systems Review

++

  • Cardiovascular/Respiratory:

    • Heart rate: 68 beats per minute

    • Blood pressure: 108/76 mm Hg

    • Respiratory rate: 18 breaths per minute

  • Cognition and Communication:

    • Alert and oriented times three and able to follow multistep commands.

    • Independent for basic and social communication; speech is fluent, with biographical naming intact.

    • Pleasant and cooperative throughout the examination process, with a mildly flat affect noted.

    • Mild difficulty with short- and long-term recall, number skills, concentration, and auditory comprehension/processing time.

  • Vision:

    • Slight ptosis of right eye noted.

    • Extraocular motions intact, with pupils equally round and reactive to light and accommodation.

    • Reports no loss of vision, blurred vision, or double vision; wears glasses for distance.

  • Musculoskeletal System:

    • Gross range of motion (ROM): Right lower extremity (LE) shows mild limitations, with greatest limitations in hip extension and ankle dorsiflexion (Table CS13.1).

    • Gross strength: Right LE shows mild losses in hip and ...

Pop-up div Successfully Displayed

This div only appears when the trigger link is hovered over. Otherwise it is hidden from view.