The document contains a clinical history and physical notes for a 52-year-old male patient presenting with cerebral ischemia (ischemic stroke). Key details include: - The patient experienced sudden severe headache, dizziness, and slurred speech. Exam found facial drooping and difficulties with coordination and swallowing. - Medical history includes hypertension and hypercholesterolemia. Surgical history includes prior neck surgery. - Diagnostic tests (CT scan, MRI) found an ischemic stroke in the middle cerebral artery, with signs of intravascular thrombus. - Assessment identifies the leading diagnosis as cerebral ischemia. Differential diagnoses include hemorrhagic stroke, subdural hemorrhage, and

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Academic Clinical History & Physical Notes for Cerebral
Ischemia
Muhammad Aftkhar
Grand Canyon University
December 04th, 2020
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

2. 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

3. 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
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.

4. 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
· 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

5. 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.
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

6. · 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
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)

7. 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
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)

8. · 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
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

9. 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
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.,

10. 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.
Name:
Date:
Section:
Studying the Old Testament Narratives
Passage: Numbers 21:4-9
Instructions:
For this assignment, you will be studying the Old Testament
story of The Bronze Serpent found in Numbers 21:4-9. You will
use the template below in order to complete a study of this
passage. In your study, you will use the skills of Observation,
Interpretation, Correlation, and Application that you have
become familiar with through your reading in Everyday Bible
Study.
I. Observation
A. I have read Numbers 21:4-9 in both a formal translation
(KJV, NKJV, NASB, ESV, or
CSB) and a functional translation (NIV, NLT, or NCV).
Highlight the correct answer. You will find a copy of the
NASB, ESV, CSB, and NLT in your myWSB Library.
· Yes
· No
B. Having read the passage in both formal and functional
translation, list at least 2 similarities and 3 differences between

11. the way both translations cover this story. You may list as many
similarities and differences that you find as long as you meet
the minimum amount.
Similarities
Differences
C. Identify the basic elements of the story you are studying
1. Main characters: (List them)
2. Plot: (50-100 words)
3. Narrative structure: (50-100 words)
Hint: Be sure to consult the section on narrative/story structure
given in the tutorial for this assignment.

12. C. List basic observations about this passage using the “Key
Question” for observation.
1. Who:
2. What:
3. Where:
4. When:
5. Why:
6. How:

13. II. Interpretation
A. Determine the author’s main point. In 1-2 paragraphs (100-
400 words) explain what you
think the author is trying to communicate in this passage.
Remember, the Old Testament narratives frequently
communicate truth by showing it to us in story form instead of
telling it to us by way of teaching or sermon. Please remember
that words like “I,” “We,” “Us, and “Our” are application words
and not interpretation words. Interpretation is about “then and
there” and not “here and now.” We were not there so the
passage is not about us. Our “part” in the passage is application
or how we will respond to God’s Word.
B. Based on your answer above, write out one principle from
this passage. You should be able
to express this principle in 1-3 sentences.
III. Correlation

14. A. How does this Old Testament narrative fit within the
metanarrative of the Bible? State what
type of story you believe this to be (creation, fall, redemption,
or new creation) and explain why you believe this to be so.
Your explanation should be 1 paragraph (100-200 words) in
length.
B. How does your principle fit with the rest of the Scripture?
This principle is the one you have
written out in 1-3 sentences in the Interpretation section. If your
principle is a true Biblical principle it will be reflected
throughout the Scriptures. Where is the principle discovered in
this Old Testament narrative found elsewhere in the Scriptures?
Your explanation should be 1 paragraph (100-200 words) in
length.
C. How does this Old Testament narrative reflect the person
and work of Jesus Christ? State

15. and explain at least one way that the principle of this narrative
can be identified in the person and work of Jesus Christ. Your
explanation should be 1 paragraph (100-200 words) in length.
IV. Application
What points of application can be made using the Four
Questions for Application? State and explain 1 point of
application for each of these four questions. Your explanation
for each of these points should be 1 paragraph (100-200 words)
in length.
A. The question of duty
B. The question of character

16. C. The question of goals
D. The question of discernment
Rubic_Print_FormatCourse CodeClass CodeANP-650ANP-650-
XO0103XBCriteriaPercentageExcellent
(100.00%)CommentsPoints EarnedContent70.0%History and
Physical Note (Chief Complaint, HPI, Patient History, Home
Medications, Review of Systems, Vital Signs, Physical Exam,
Test Results)20.0%The history and physical note is thoroughly
explored and clearly explained with relevant details and
support.Assessment and Clinical Impressions (Identification of
Three Differential Diagnoses, List of Acute and Chronic
Diagnoses, List of Diagnoses and Conditions in Priority
Order)20.0%The assessment and clinical impressions are
thoroughly explored and clearly explained with relevant details
and support.Plan Component Management and Criteria
Incorporation (Interventions, Disposition, Expected Outcomes,
Health Education, and Case Summary)20.0%The plan
component management and plan criteria incorporation are
thoroughly explored and clearly explained with relevant details
and support.Peer-Reviewed Articles10.0%Three peer-reviewed
articles are included.Organization and
Effectiveness10.0%Mechanics of Writing (includes spelling,
punctuation, grammar, language use)10.0%Writer is clearly in
command of standard, written, academic
English.Format20.0%Paper Format (Use of appropriate style for
the major and assignment)10.0%All format elements are

17. correct.Documentation of Sources (citations, footnotes,
references, bibliography, etc., as appropriate to assignment and
style)10.0%Sources are completely and correctly documented,
as appropriate to assignment and style, and format is free of
error.Total Weightage100%
Academic Clinical History and Physical Note 1
Academic clinical history and physical notes provide a unique
opportunity to practice and demonstrate advanced practice
documentation skills, to develop and demonstrate critical
thinking and clinical reasoning skills, and to practice
identifying acute and chronic problems and formulating
evidence-based plans of care.
Complete an academic clinical history and physical note based
on a patient seen during clinical. In your assessment, provide
the following.
History and Physical Note
1. Chief complaint/reason for admission/visit/consult.
2. HPI for the H&P or consult notes.
3. Medical, surgical, family, social, and allergy history.
4. Home medications, including dosages, route, frequency, and
current medications, if a consultation note
5. 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).
6. Vital signs and weight.
7. Physical exam with a complete head-to-toe evaluation.
Include pertinent positives and negatives based on findings
from head-to-toe exam.
8. Lab/Imaging/Diagnostic test results (including date).
Assessment and Clinical Impressions
1. Identify at least three differential diagnoses based upon the
chief complaint, ROS, assessment, or abnormal diagnostic tools
with rationale.

18. 2. Include a complete list of all diagnoses that are both acute
and chronic.
3. List the differential diagnoses and chronic conditions i n order
of priority.
Plan Component Management and Plan Criteria Incorporation
1. Select appropriate diagnostic and therapeutic interventions
based on efficacy, safety, cost, and acceptability. Provide
rationale.
2. Discuss disposition and expected outcomes.
3. Identify and address health education, health promotion, and
disease prevention.
4. Provide case summary with ethical, legal, and geriatric
considerations. Consider potential issues, even if they are not
evident.
General Requirements
Incorporate at least three to Five peer-reviewed articles in the
assessment or plan. Words count should be between 1000-1500.
While APA style is not required for the body of this assignment,
solid academic writing is expected, and documentation of
sources should be presented using APA formatting guidelines,
which can be found in the APA Style Guide, located in the
Student Success Center.
This assignment uses a rubric. Please review the rubric prior to
beginning the assignment to become familiar with the
expectations for successful completion.