Comprehensive Stroke Case Study

Patient Chart

Patient Name: John Robert Miller
Date of Birth: 08/15/1957
Age: 67
Gender: Male
Medical Record Number: 20250318
Date of Admission: 03/18/2025
Primary Care Provider: Dr. Patricia Harrison

Chief Complaint (CC)

"I can't feel the right side of my body and my speech is slurred."

History of Present Illness (HPI)

John Miller, a 67-year-old male, presents to the emergency department with acute onset of right-sided weakness, slurred speech, and facial drooping. The patient reports that the symptoms began approximately 1.5 hours before arrival. He denies any headache, nausea, or vomiting but describes a feeling of dizziness and difficulty speaking clearly. He was watching television when he suddenly noticed that he couldn’t lift his right arm or leg, and his wife observed that his speech had become difficult to understand.

The patient has no history of recent trauma or falls and denies any loss of consciousness. His symptoms have been constant since their onset. His wife called emergency services immediately, and they arrived promptly.

Past Medical History (PMH)

• Hypertension – diagnosed 12 years ago, poorly controlled on current medications
• Hyperlipidemia – diagnosed 5 years ago
• Type 2 Diabetes Mellitus – diagnosed 10 years ago, controlled with Metformin
• Atrial Fibrillation – diagnosed 3 years ago, managed with warfarin
• Previous transient ischemic attack (TIA) – 2 years ago
• No history of stroke.

Surgeries & Procedures

• Cardiac catheterization (4 years ago) for coronary artery disease
• Electrophysiological study (2 years ago) for atrial fibrillation, no ablation performed

Allergies

• Warfarin – Mild rash
• Aspirin – Gastric irritation

Medications

• Warfarin 5 mg daily (for atrial fibrillation)
• Metformin 1000 mg twice daily (for type 2 diabetes)
• Lisinopril 20 mg daily (for hypertension)
• Simvastatin 20 mg at bedtime (for hyperlipidemia)

Family History (FH)

• Father: Deceased, 80, with a history of stroke and hypertension
• Mother: Alive, 85, with a history of heart disease and diabetes
• Brother: Alive, 60, with a history of hypertension and hyperlipidemia
• Paternal Grandfather: Died of a stroke at age 75

Social History (SH)

• Smoking: Former smoker, quit 10 years ago after smoking for 20 years
• Alcohol: Occasionally drinks (2-3 drinks/week)
• Drug Use: Denies illicit drug use
• Occupation: Retired accountant
• Living Situation: Lives with wife, independent in activities of daily living

Review of Systems (ROS)

• General: No fever, weight loss, or night sweats
• Cardiovascular: No chest pain, palpitations, or edema
• Respiratory: No shortness of breath or cough
• Gastrointestinal: No nausea, vomiting, or abdominal pain
• Neurological: Slurred speech, right-sided weakness, dizziness, no loss of consciousness
• Musculoskeletal: No joint pain or muscle weakness
• Psychiatric: No anxiety, depression, or recent changes in mood

Physical Assessment Findings

Vital Signs:

• Temperature: 98.6°F (37°C)
• Heart Rate: 85 bpm, irregularly irregular
• Respiratory Rate: 18 breaths/min
• Blood Pressure: 180/100 mmHg
• Oxygen Saturation: 98% on room air

General Appearance: Overweight male, alert but with slurred speech, appearing mildly distressed
Cardiovascular: Irregularly irregular rhythm, no murmurs or gallops
Respiratory: Clear to auscultation bilaterally
Neurological:

• Mental Status: Alert, oriented to person, place, and time, but speech is slurred (aphasia)
• Cranial Nerves: Facial droop on the right side, unable to smile symmetrically
• Motor: Right-sided hemiparesis (weakness) noted, with decreased strength in right upper and lower limbs (3/5 strength)
• Sensory: Decreased sensation to light touch and pinprick on the right side
• Coordination: Difficulty with right hand movements, unable to perform finger-to-nose test with right hand
• Gait: Unable to walk independently, requires assistance

Laboratory Results

Complete Blood Count (CBC)

Basic Metabolic Panel (BMP)

Coagulation Panel

Brain Imaging (CT Head)

• Findings: Acute ischemic stroke in the left middle cerebral artery (MCA) territory, with evidence of significant infarction in the frontal and parietal lobes.

Nursing Diagnoses

1. Impaired Physical Mobility related to right-sided hemiparesis as evidenced by weakness and decreased strength in the right upper and lower limbs.
2. Impaired Verbal Communication related to slurred speech and aphasia as evidenced by difficulty in expressing thoughts.
3. Risk for Aspiration related to impaired swallowing and altered consciousness.
4. Risk for Cerebral Perfusion related to a history of hypertension, atrial fibrillation, and the presence of an ischemic stroke.

Plan of Care (Interventions & Rationale)

• Administer anticoagulants (e.g., warfarin or other recommended agents) as per stroke protocol to prevent further clot formation