CVA Medical Report: Patient Scenario and Diagnostic Procedures

This medical report presents a detailed analysis of a 53-year-old patient, Michael, admitted to the emergency ward with a severe headache, unable to walk, and experiencing palpitations, indicative of a Cerebrovascular Accident (CVA). The report meticulously documents the patient's history, including a previous Transient Ischemic Attack (TIA), occupational and social history, and family history. It outlines the physical examination findings, including restlessness, sweating, muscle stiffness, and blurred vision. The diagnosis procedure involves Magnetic Resonance Imaging (MRI) and CT scans to assess brain damage and abnormalities. The report also identifies the nervous and circulatory body systems involved and proposes a treatment plan including analgesia and rehabilitation for addiction. The report also provides an answer key for key medical terms and references used.

Running head: MEDICAL DIAGNOSIS
MEDICAL DIAGNOSIS ASSIGNMENT
Name of the student
Name of the university
Author note

1MEDICAL DIAGNOSIS
Patient scenario
The patient Michael (53) was admitted to the emergency ward of healthcare facility
after having severe head ache. At 20:30 Hrs. the receptionist of the healthcare facility
received a call from the emergency medical handling department stating that an older adult is
suffering from severe head ache and is unable to walk and severely palpitating and requires
emergency medical assistance. Upon admission in the healthcare facilities emergency
department he was accompanied with his wife Maria (51) who was informed about his
health condition by grocery shop owners.
History of present illness (HPI)
After admission in the ward, at 21:27 Hrs. Maria was asked about Michael’s past
healthcare conditions so that present chronic condition and its presence in patients’ health
history could be identified. Maria stated that 3 years back Michael was admitted to the
healthcare facility for transient ischemic attack which is also known as mini stroke. As per
Sczepanski and Bozyk (2018), patients affected with transient ischemic attack develop
higher risk of cerebro- vascular accident (CVA), if they do not comply with the provided
preventive measures. Hence, the pain Michael developed could be the adverse condition of
his transient ischemic attack which leads to cerebro- vascular accident.
Chief complaint (CC)
The patient was unable to speak in a complete sentence hence, his fragmented speech
were accumulated to understand his chief complaint. The primary concern of the patient was
his severe head ache, and was feeling stiffness in muscles due to which he suffered from
severe distress. As per Kase et al. (2017), patients suffering from cerebro- vascular
accident develop weakness and stiffness in muscles and are restlessness due to such
condition. As per Jashari et al. (2016), majority of patients suffering from cerebro- vascular

2MEDICAL DIAGNOSIS
accident develops symptoms of difficult speech, palpitating, distress, overactive reflexes
and paralytic condition. Michael was also seen sweating, and palpitating and complaint of
severe pain in the left upper quadrant of his body. Patient also complaint of blurred and
double vision and hence, as per Sczepanski and Bozyk (2018) indicated towards his cerebro-
vascular accident condition.
Occupational history (OH)
Michael was unable to speak and hence, Maria was questioned about patient’s
occupational health upon which it was observed that patient works as a mining site truck
driver and used to compliant of headache every now and then. Upon visiting a local
healthcare dispensary, he was identified with transient ischemic attack and was on opioids
and plasminogen activator since then. As per Rao et al. (2017), majority of the patients
suffering from transient ischemic attack are at high risk of cerebro- vascular accident
condition. However, the workplace of the patient is a crucial in this condition as due to the
severe stress and depression of the workplace lead to pressure in the artery that leads to clots
in artery and hence, returning to the same working environment could add to the risk factors
of his existing health condition.
Social History (SH)
As per Maria, Michael is a chain smoker and social drinker. After the episodes of
transient ischemic attack, he reduced his smoking and drinking habits however, after the
death of their son in a car accident, his additive habits relapsed. As per Reichert et al. (2016),
due to smoking habits majority of the patients suffering from transient ischemic attack
could lead to cerebro- vascular accident condition.

3MEDICAL DIAGNOSIS
Family history
The patient is 53 year old male and has history of health condition and stroke due to
which he was admitted to hospital 3 years ago. Upon asking about presence of such
healthcare condition in the family of Michael it was observed that no such information is
available so that his current health condition could be related to his family history.
1. Physical examination (PE):
Upon admission, the patient seemed restless and was constantly palpitating, he was
profusely sweating and seen suffering from severe head ache. He was unable to more his
left quadrant of his body and was complaining of numbness and stiffness in his muscles. He
was unable to speak and also had blurred vision with reduced sensation. To assess this
physical signs and symptoms registered nursing professionals would be involved so that
all the physical examination of the patient followed by collection of vital signs could help in
identification of health complication.
2. Diagnosis procedure
The diagnosis of patient’s health complication would be done by applying magnetic
resonance imaging or MRI. As per Duchin et al. (2018), MRI is a non- invasive healthcare
diagnosis process that helps to identify the brain and its anatomy so that using the magnetic
radio waves of the diagnostic tool brain tissue damage of the of the patients’ brain and
presence of haemorrhage could be assessed. Further CT scan would also be used which helps
to identify the abnormalities present in the brain cells by performing a series of x-ray of
patients brain so that identification of abnormalities could be identified.
3. Other body system involved:
Besides heart concern (nervous system), he was presented with heaviness in chest
(circulatory body system) due to which he was sweating heavily and constantly fidgeting.

4MEDICAL DIAGNOSIS
As per Nishimura et al. (2017), improper and delayed treatment of cerebro- vascular
accident is associated to high risk factors for cardiac issues and hence, identification of this
would help to provide the patient with effective intervention.
4. Plan (P)
To relieve the severe head ache, the patient would be provided with analgesia as
potential opiate and intravenous tissue plasminogen activator helps to relieve the severe
pain associated with this severe health condition. Further, it was seen that patient is unable to
control his smoking and drinking habits and hence, he would be asked to join a
rehabilitation centre so that he could overcome his addictions and associated health
conditions.

5MEDICAL DIAGNOSIS
Answer key sheet
1. Cerebro- vascular accident: This is a medical term which is used for stroke.
2. Transient ischemic attack: A short period of neurological dysfunctioning in
which the blood supply to the brain is affected
3. Addiction: It is a phase of repeated involvement with any substance.
4. Palpitation: It is the rapid and irregular heartbeat that arises due to the severe
health condition, stress or agitation.
5. Intravenous tissue plasminogen activator: It is a type of enzyme which is
provided to the patients to remove blood clots from their artery.
6. Health history: it is a problem focused assessment which is used to understand
the past health condition of the patient involved.
7. Emergency medical department: it is the service which helps to treat emergency
healthcare conditions in which rapid and fast assistance is required.
8. Headache: continuous pain in head of the patient
9. Medical assistance: it si the service which is provided to the patient for the health
improvement.
10. Delayed treatment: it is the phase in which the patient is not provided with rapid
and accurate medication, affecting their health condition.
11. Diagnosis: identification of patients’ health condition characterized by symptoms
that help to determine the illness.
12. Physical examination: it is type of medical examination conducted to determine
physical fitness of patient
13. Body system: it is a group of tissues that develops a particular health system.
14. Nervous system: it is group of nerve cells that with the help of neurological
impulses connect every part of body.

6MEDICAL DIAGNOSIS
15. Circulatory body system: It is the system that helps to move blood throughout
the body
16. Occupational history: it is a chronological detail of patients’ workplace, so that
their occupational exposure could be obtained.
17. Stiffness of muscles: it is the tightness in the muscle that makes the muscle
movement difficult and painful.
18. Numbness of muscles: it is the prickling sensation that arises due to illness or
weakness.
19. Stroke: sudden death if brain cells due to lack of blood flow and subsequent
oxygen flow.
20. MRI: medical resonance imaging technique used to diagnose abnormalities of
brain.
21. CT scan: it is a detailed x-ray technique which helps to understand
abnormalities present in the human brain.

7MEDICAL DIAGNOSIS
References
Duchin, Y., Shamir, R. R., Patriat, R., Kim, J., Vitek, J. L., Sapiro, G., & Harel, N. (2018).
Patient-specific anatomical model for deep brain stimulation based on 7 Tesla
MRI. PloS one, 13(8), e0201469.
Jashari, F., Ibrahimi, P., Bajraktari, G., Grönlund, C., Wester, P., & Henein, M. Y. (2016).
Carotid plaque echogenicity predicts cerebrovascular symptoms: a systematic review
and meta‐analysis. European journal of neurology, 23(7), 1241-1247.
Kase, H., Mori, A., Waki, Y., Ohsawa, Y., Karasawa, A., & Kuwana, Y. (2017). U.S. Patent
Application No. 15/413,898.
Nishimura, R. A., Otto, C. M., Bonow, R. O., Carabello, B. A., Erwin, J. P., Fleisher, L.
A., ... & Rigolin, V. H. (2017). 2017 AHA/ACC focused update of the 2014
AHA/ACC guideline for the management of patients with valvular heart disease: a
report of the American College of Cardiology/American Heart Association Task
Force on Clinical Practice Guidelines. Journal of the American College of
Cardiology, 70(2), 252-289.
Rao, A., Jones, A., Bottle, A., Darzi, A., & Aylin, P. (2017). A retrospective cohort study of
high-impact users among patients with cerebrovascular conditions. BMJ open, 7(6),
e014618.
Reichert, S., Schulz, S., Benten, A. C., Lutze, A., Seifert, T., Schlitt, M., ... & Schlitt, A.
(2016). Periodontal conditions and incidence of new cardiovascular events among
patients with coronary vascular disease. Journal of clinical periodontology, 43(11),
918-925.

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Sczepanski, M., & Bozyk, P. (2018). Institutional Incidence of Severe tPA-Induced
Angioedema in Ischemic Cerebral Vascular Accidents. Critical care research and
practice, 2018.