1 15 Academic Clinical History & Physical Notes for Cerebral Ischemia I am presenting the academic clinical history and physical notes for the patient of ischemic stroke. Ischemic stroke or cerebral ischemia occurs when one of the cerebral arteries is blocked by the clot leading to diminished blood supply and oxygen to brain cells resulting in damage or death of brain cells (Celik et al., 2020) History and Physical Note 1.Chief complaint/reason for admission/visit/consult. A 52 years old male patient came to the acute care hospital with the chief complaint of sudden severe headache, dizziness, and slurred speech. HPI for the H&P or consult notes. The patient felt a severe burning and shooting pain in the frontal region of the head while he was reading the newspaper in the morning. The patient said that he developed blurred vision during reading. The patient felt numbness when the pain started (Harriot et al., 2020). The patient said that the pain was not subsiding with the time as it persisted since its onset. The pain scale was nine by 10, started in the frontal region, and radiated towards the temporal region. The associated symptoms with pain are nausea, vomiting, aphasia, dysarthria, apraxia, and vertigo (De Cock, et al., 2020). The symptoms become aggravate in a standing position and become alleviating when he lay down on the bed with 3 pillows. The patient felt a significant change in body posture. He is positive for facial drooping while negative for fever and chills. He finds difficulty in sitting and maintaining coordination. The patient stated that he had a medical history of neck trauma in a road accident. He was hospitalized for 3 weeks after neck surgery. 2.Medical, surgical, family, social, and allergy history. Medical history The patient has hypertension and hypercholesterolemia (Haegens, et al., 2018). Surgical history The patient underwent neck surgery after neck trauma at the age of 42. Family history The patient’s mother is alive and diabetic. The father of the patient died due to a cardiac stroke. His sister is normal. One of the two brothers has hypertension, and the other is normal. Currently, the patient is living with his normal wife. Social history The patient has a long history of smoking and boozing, coupled with a sedentary lifestyle. Allergy history · Raw fruits and vegetables, Shellfish, Soy. · Amoxicillin and aspirin. 3.Home medications, including dosages, route, frequency, and current medications, if a consultation note. Antihypertensive drugs Edarbi & Hygroton. 40 mg oral Edarbi once a day, as the patient is on diuretics, Hygroton. Oral 50 mg Hygroton once in the morning. Hypercholesterolemic drugs Lipitor Oral tablet 40 mg once a day. He takes this tablet at night. 4.Review of systems with all body systems for H&P or consult notes. Review of systems is what the patient or family/friends tell you (by body system). General appearance The patient shows facial we ...

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15
Academic Clinical History & Physical Notes for
Cerebral Ischemia
I am presenting the academic clinical history and physical notes
for the patient of ischemic stroke. Ischemic stroke or cerebral
ischemia occurs when one of the cerebral arteries is blocked by
the clot leading to diminished blood supply and oxygen to brain
cells resulting in damage or death of brain cells (Celik et al.,
2020)
History and Physical Note
1.Chief complaint/reason for admission/visit/consult.
A 52 years old male patient came to the acute care hospital with
the chief complaint of sudden severe headache, dizziness, and
slurred speech.
HPI for the H&P or consult notes.
The patient felt a severe burning and shooting pain in the
frontal region of the head while he was reading the newspaper
in the morning. The patient said that he developed blurred
vision during reading. The patient felt numbness when the pain
started (Harriot et al., 2020). The patient said that the pain was
not subsiding with the time as it persisted since its onset. The
pain scale was nine by 10, started in the frontal region, and
radiated towards the temporal region. The associated symptoms
with pain are nausea, vomiting, aphasia, dysarthria, apraxia, and
vertigo (De Cock, et al., 2020). The symptoms become
aggravate in a standing position and become alleviating when he
lay down on the bed with 3 pillows. The patient felt a
significant change in body posture. He is positive for facial
drooping while negative for fever and chills. He finds difficulty
in sitting and maintaining coordination. The patient stated that

2. he had a medical history of neck trauma in a road accident. He
was hospitalized for 3 weeks after neck surgery.
2.Medical, surgical, family, social, and allergy history.
Medical history
The patient has hypertension and hypercholesterolemia
(Haegens, et al., 2018).
Surgical history
The patient underwent neck surgery after neck trauma at the age
of 42.
Family history
The patient’s mother is alive and diabetic. The father of the
patient died due to a cardiac stroke. His sister is normal. One of
the two brothers has hypertension, and the other is normal.
Currently, the patient is living with his normal wife.
Social history
The patient has a long history of smoking and boozing, coupled
with a sedentary lifestyle.
Allergy history
· Raw fruits and vegetables, Shellfish, Soy.
· Amoxicillin and aspirin.
3.Home medications, including dosages, route, frequency, and
current medications, if a consultation note.
Antihypertensive drugs Edarbi & Hygroton.
40 mg oral Edarbi once a day, as the patient is on diuretics,
Hygroton. Oral 50 mg Hygroton once in the morning.
Hypercholesterolemic drugs Lipitor
Oral tablet 40 mg once a day. He takes this tablet at night.
4.Review of systems with all body systems for H&P or consult
notes. Review of systems is what the patient or family/friends
tell you (by body system).
General appearance
The patient shows facial weakness, numbness, confusion,
sweating, and dizziness. Facial drooping present.
HEENT
No epistaxis, no tinnitus, mild sinus pain, mild ear pain. No oral
lesions, gingival bleeding, and dental pain; however, dysphagia

3. and aphasia are present.
Eyes
Visual changes present, headache, eye pain, and blurred vision.
Cardiovascular
Short breathing, loss of consciousness, fainting was present—
claudication and palpitations present.
Pulmonary
Hiccups, short breathing, mild cough present.
Gastrointestinal
No abdominal pain, no cramps. However, nausea, vomiting, and
difficulty in swallowing present.
Genitourinary
No dysuria, hematuria, nocturia. Vo obvious genitourinary
complications observed.
Integumentary
Mild skin rash, no lesions, no wound, no physical trauma, and
skin is intact. However, an incisional line is present in the neck
region due to neck surgery.
Musculoskeletal
Unilateral numbness of the face, arm, and leg. Muscle
weakness, paralysis on the left side, stiffness. Difficulty in
movement and maintaining body posture.
Neurological
blurred vision, normal smell sense, normal taste, and hearing.
Severe headache, numbness, limb weakness, faintness, and fits
present.
Psychiatric
Stress, confusion, anxiety, disturbed sleep patterns, and
personality changes.
Endocrine system
Mild overactive adrenal gland and underactive thyroid
functions.
5.Vital signs and weight.
Weight
· 154 lbs.
Vital signs

4. · Temp = 98F, HR = 66bpm, O2= 98%, RR = 1.21, BP =
138/92mmHg.
6.Physical exam with a complete head-to-toe evaluation.
General
The patient looked panicked, confused, and weak.
Eyes
Eye pain and blurred vision.
ENT
Difficulty in swallowing. Abnormal head positioning, nose
bleeding not present, mild ear pressure. Normal oral mucosa. No
obstruction, no sinus pain. No hoarseness.
NECK
Mild neck stiffness, incisional line on the right side of the neck
due to neck surgery. No palpable swelling.
Lymph nodes
No lymphadenopathy
Cardiovascular
Normal cardiac sounds with no noticeable vibrations. No chest
pain; however, dyspnea present.
Respiratory
Short breathing, mild cough, dyspnea, and wheezing are present.
Integumentary
No skin rash or bruise, intact warm skin; however, frequent
sweats with no erythematous areas.
Neurological
Severe throbbing headache, tremors and ataxia, loss of
sensation, memory loss, and slurred speech.
Psychiatric
Stress, anxiety, confusion present. Fear for the ongoing
symptoms of the disease was present. Insomnia and depressed
mood.
Endocrinal
Loss of appetite, with polyuria and polydipsia.
Genitourinary
No urinary tract infection, no rash, no sexually transmitted
disease. However, polyuria is observed.

5. Gastrointestinal
A normal bowel movement, no constipation, no bloating.
Musculoskeletal
Right arm and leg paresthesia, difficulty in movement, and
standing.
Extremities
No edema, clubbing, and cyanosis.
Include pertinent positives and negatives based on findings
from the head-to-toe exam.
Positives
· Anorexia
· Polyuria
· Depressive mood swings
· Insomnia
Negatives
· Urinary tract infection
· Edema
· Heartburn
7.Lab/Imaging/Diagnostic test results (including date). (CPT
codes).
CBC
· RBC (Code 82482) = 6.4 cells/mcL, Platelet count (Code
85049) = 370,000.
Coagulation tests PT, PTT, INR
· Prothrombin time PT (Code 85610) = 8 secs
· Partial thromboplastin PTT (Code 117796) = 19 secs
· International normalized ratio INR (Code 93793) = .9
Lipid profile (Code 80061)
· Total cholesterol = 190mg/dl
· Non- HDL = 130mg/dl
· LDL = 110mg/dl
· HDL = 55mg/dl
Imaging Diagnostic tests
CT Scan (Code 70460)
The scan shows an ischemic stroke of the middle cerebral

6. artery. A darker, less dense area in the middle cerebral artery is
observed.
MRI (Code 70553)
The ischemic lesion is observed in the middle cerebral artery
with signs of intravascular thrombus.
Assessment and Clinical Impressions
1. Identify at least three differential diagnoses based upon the
chief complaint, ROS, assessment, or abnormal diagnostic tools
with rationale. (ICD-10 codes)
· Brain tumor (ICD-10-CM C71)
· Hemorrhagic stroke (ICD-10-CM C161.9)
· Subdural hemorrhage (ICD-10-CM C162)
· Neurosyphilis (ICD-10-CM A52)
· Hypertensive encephalopathy (ICD-10-CM 167.4)
2. Include a complete list of all diagnoses that are both acute
and chronic.
· Cerebral Ischemia (ICD-10-CM 167.82)
· Complex or atypical migraine (ICD-10-CM 109)
· Wernicke’s encephalopathy (ICD-10-CM E51.2)
· CNS abscess (ICD-10-CM G06.0)
· Meningitis (ICD-10-CM G03.9)
· Multiple sclerosis (ICD-10-CM G35)
· Transient global amnesia (ICD-10-CM G45.4)
· Cerebral amyloid angiopathy (ICD-10-CM 168)
Rationale
· Brain tumor (ICD-10-CM C71)
The brain tumor is an abnormal growth of brain cells that
results in increased intracranial pressure leading to severe
headache in the morning, insomnia, and fatigue. The rationale
for selecting a brain tumor as the differential diagnosis is the
prime symptoms and the relative time of occurrence of these
symptoms as the patient felt severe headache with seizures,
fatigue, and drowsiness.
· Hemorrhagic stroke (ICD-10-CM C161.9)
When a blood vessel breach and drain blood into the tissue of
brain and brain cells begin to die causing the loss of

7. consciousness, severe headache, and seizures. I put hemorrhage
stroke on the top of the list of differential diagnosis as the
patient displays neck stiffness. Additionally, he has a long
history of hypertension.
· Subdural hemorrhage (ICD-10-CM C162)
Subdural hemorrhage manifests bleeding between the brain dura
matter due to head injury leading to headache, confusion,
slurred speech, and rapid mood swings. The rationale for
subdural hemorrhage is to figure out the underlying cause of
post-traumatic brain conditions as the patient has neck surgery
at the age of 42 and exhibiting the symptoms of dizziness,
nausea, and confusion associated with a severe headache.
3.List the differential diagnoses and chronic conditions in order
of priority.
I prioritize the differential diagnosis according to the current
physical findings.
· Cerebral Ischemia (ICD-10-CM 167.82)
· Hemorrhagic stroke (ICD-10-CM C161.9)
· Subdural hemorrhage (ICD-10-CM C162)
· Brain tumor (ICD-10-CM C71)
· Neurosyphilis (ICD-10-CM A52)
· Hypertensive encephalopathy (ICD-10-CM 167.4)
· Meningitis (ICD-10-CM G03.9)
· CNS Abscess (ICD-10-CM G06.0)
· Transient amnesia (ICD-10-CM G45.4)
· Cerebral amyloid angiopathy (ICD-10-CM 168)
Plan Component Management and Plan Criteria Incorporation
1.Select appropriate diagnostic and therapeutic interventions
based on efficacy, safety, cost, and acceptability. Provide a
rationale.
The main objective of the treatment intervention is to restore
the blood supply to the part of the brain where the block occurs.
An emergency IV medication is administered to break up or
dissolve the clot (Hawkes et al., 2020). Endovascular therapy in

8. which a thin catheter is inserted through an artery directly
approaches the stroke area for urgent blood supply to the
affected area. These methods are efficient and cost-effective
indeed and ensure the safety of the patient. Moreover,
Diagnostic interventions involve pre-and post-procedure CT
scans and MRI to assess the location and dissolution of the clot
(Muller et al., 2020).
The rationale for treatment interventions
The rationale for this intervention is to restore the blood supply
to the stroke area by surgical or non-surgical interventions to
secure the life of the patient.
2.Discuss disposition and expected outcomes.
The treatment outcomes are productive, as we will dissolve the
clot by IV medication more quickly. Moreover, the
catheterization provides successful revascularization of the
affected area to restore the brain's blood supply.
3.Identify and address health education, health promotion, and
disease prevention.
Through health education programs, the population would be
able to understand the risk factors of cerebral ischemia. Health
promotion programs involve using a healthy diet, healthy
lifestyle, and cessation of non-healthy habits such as smoking,
drinking, and high sugar and fats consumption that lead to
blockage of arteries. These programs help in reducing the risk
factors, ultimately creating ways for disease prevention.
4.Provide a case summary with ethical, legal, and geriatric
considerations. Consider potential issues, even if they are not
evident.
Cerebral ischemia is a serious medical condition in which there
is little chance of functional recovery. The provision of an
advance directive or living Will is necessary for the patient as
he can express his feelings about his medical predicament.
However, in this condition, the family and health care providers
should pursue clinical interventions according to the patient's
safety demands without any delay. Additionally, the will of
geriatric patients with cerebral ischemia should be considered

9. before any major clinical intervention.
References
Çelik, Ö., Güner, A., Kalçık, M., Güler, A., Demir, A. R.,
Demir, Y., ... &Ertürk, M. (2020). The predictive value of
CHADS2 score for subclinical cerebral ischemia after carotid
artery stenting (from the PREVENT‐ CAS
trial). Catheterization and Cardiovascular Interventions.
De Cock, E., Batens, K., Hemelsoet, D., Boon, P., Oostra, K., &
De Herdt, V. (2020). Dysphagia, dysarthria, and aphasia
following a first acute ischemic stroke: incidence and associated
factors. European Journal of Neurology.
Harriott, A. M., Karakaya, F., &Ayata, C. (2020). Headache
after ischemic stroke: A systematic review and meta-
analysis. Neurology, 94(1), e75-e86.
Haegens, N. M., Gathier, C. S., Horn, J., Coert, B. A., Verbaan,
D., & van den Bergh, W. M. (2018). Induced hypertension in
preventing cerebral infarction in delayed cerebral ischemia after
subarachnoid hemorrhage. Stroke, 49(11), 2630-2636.
Hawkes, M. A., Hlavnicka, A. A., &Wainsztein, N. A. (2020).
Reversible cerebral vasoconstriction syndrome is responsive to
intravenous milrinone. Neurocritical Care, 32(1), 348-352.
Muller, S., Dauyey, K., Ruef, A., Lorio, S., Eskandari, A.,
Schneider, L., ... &Kherif, F. (2020). Neuro-Clinical Signatures
of Language Impairments after Acute Stroke: A VBQ Analysis
of Quantitative Native CT Scans. Current Topics in Medicinal
Chemistry, 20(9), 792-799.