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Case Study on Stroke Patient

Case Study on Stroke Patient

Time and date of arrival: April 5th, 2011 @ 10:24am
Place of arrival: ER
Name: Tyrone Williams
Age: 66
Gender: Male
Race: African American

Symptoms and complaints reported: Abrupt loss of vision and difficulty speaking. Reported sudden loss of strength and coordination (mostly in left side) accompanied by loss of balance.

Medical History: Has history of high blood pressure and high cholesterol. Sedentary lifestyle. Heavy smoker. Absence of all other major illnesses noted.

Family History: No siblings. Father is a heavy smoker and has had two strokes in the past three years. Mother suffers from obesity. Grandparents died of old age and not of a major illness. No other major illness noted.

Social History: No heavy drinking. Smokes 2-3 packs of light cigarettes daily. Sedentary lifestyle. Lives in apartment alone. Works full time as sales executive for Sears Department Store.

Physical assessment: High blood pressure of 130/95. High cholesterol. Overweight (height is 5,11 @ 275lbs. Pulse is 95bpm. Temperature is 98.8 C. Respiratory rate is 18. Patient is somewhat confused and suffers from blurred vision, slurred speech and loss of balance.

Tests: CT scan and MRI reveal a thrombus clot in the right side of the brain. Physical exam and reflex exam not to full potential. Muscles respond weakly. Left side responds worse and more slowly than right side of body. Neurological exam: abnormal. No ischemia.

Diagnosis: Thrombus clot stroke.

Planning and Implementation: Anticoagulant medication and counseling for improvement of lifestyle (i.e. eating habits).

Evaluation: Patient discharged home with anticoagulants as a permanent prescription after being closely monitored in the hospital for two days. Informed patient to rest, relax and call hospital immediately if symptoms occur again. Patient also put on a strict, healthy diet. Follow-up visit in one week.

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