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Life Threatening? No
Write-up: Patient is a 47 y.o. female who arrived by Car presented to the emergency department for Stroke symptoms. Patient awoke at 6:15 this morning, some difficulty seeing out of the right eye and also was stumbling towards the left and to table. Concerned about things not being right so brought to the emergency department. Patient feels her speaking and swallowing are okay. She did drink a bit of coffee earlier. She denies headache or significant vision problems presently. Continues to not feel normal on her left side. No history of stroke and parents or siblings. She does give personal history of an occipital migraine many years ago at which time she did not have a headache but had some vision troubles. Physical Exam Vitals signs and nursing note reviewed. Constitutional: General: She is not in acute distress. Appearance: She is not ill-appearing or diaphoretic. HENT: Head: Normocephalic and atraumatic. Right Ear: Tympanic membrane normal. Left Ear: Tympanic membrane normal. Nose: Nose normal. Mouth/Throat: Mouth: Mucous membranes are moist. Pharynx: No oropharyngeal exudate or posterior oropharyngeal erythema. Eyes: Conjunctiva/sclera: Conjunctivae normal. Pupils: Pupils are equal, round, and reactive to light. Comments: Patient displays absence of left lateral movement Neck: Musculoskeletal: Normal range of motion. No muscular tenderness. Cardiovascular: Rate and Rhythm: Normal rate and regular rhythm. Heart sounds: No murmur. Pulmonary: Effort: Pulmonary effort is normal. Breath sounds: Normal breath sounds. Abdominal: General: Bowel sounds are normal. There is no distension. Palpations: Abdomen is soft. Tenderness: There is no abdominal tenderness. Musculoskeletal: Right lower leg: No edema. Left lower leg: No edema. Lymphadenopathy: Cervical: No cervical adenopathy. Skin: Findings: No rash. Neurological: Mental Status: She is alert. Cranial Nerves: Cranial nerve deficit (left facial droop, dysarthria) present. Comments: Patient''s speech seems a bit slurred to me. Absence of ocular movements towards left noted as well as upward movements. Tongue is midline. Patient is unable to shrug the left shoulder or lift the left arm off the bed. Grip strength is 4 out of 5 on the left. Left leg strength is 3 out of 5. Extremity strength on right arm and leg is 5 out of 5. After consultation with a neurologist, the patient is being transferred from the ED.
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