Melvin Thomas is a 64-year-old man admitted to the hospital with a diagnosis of acute CVA. Listed below are data collected by the examiner during an interview and examination.
Interview Data:
Mrs. Thomas's wife tells the examiner that her husband was fine until this morning when he suddenly had a headache, fell to the floor, and could not get up. Mrs. Thomas adds that when she tried to get her husband to speak, he made only mumbling noices, and she could not understand him.
Examination Data:
Mental Status: Awake, alert male. Unable to talk but able to follow commands. Very distraught over this incident. Patient cries and avoids eye contact with his wife and the examiner.
Neurologic examination: Cranial nerves I, II, III, IV, V, VI, and VII all intact. Patient has asymmetry and unequal movements of his face, with a drooping of the left side of his face. Has asymmetry of shoulder shrug, with deficiency noted on the left side. Patient has left-sided paralysis. Demonstrates expected muscle tone and sensation on right side. Unable to assess balance. Patient unable to get up or move around in bed unassisted at this time.
Provide textbook/scholarly resources
- What additional questions could the examiner ask to clarify symptoms?
- What additional physical examination, if any, should the examiner complete?
- What primary problems does the patient have?