History Is Taken From The Patient Essay - 899 Words

Chief Complaint CVA. History History is taken from the patient, who is a good historian along with records from her inpatient stay at Portsmouth Regional Hospital and her outpatient visit for Dr. Tan. In short, she is a 64-year-old right-handed white female who on August 8, 2015 awoke with acute weakness on the right side of her body. She had difficulty getting out of bed. She was able to move around and walk, but she had noted coordination problems. She called family who was concerned about her slurred speech. After they arrived, they recommended that she go to the emergency room. The patient did not notice any visual field cut. She did not notice any language problems other than slurred speech. There was no dizziness. No significant sensory changes. She has no history of palpitations. Her risk factors are all poorly controlled diabetes, hypertension, hypercholesterolemia, and cigarette smoking. She was not on an aspirin a day at the time of her event. She presented to the emergency room, where she noted significant improvement. She was discharged with minimal findings on the right side for outpatient physical therapy. She has one more physical therapy visit on Thursday. Currently, she states that she has no problems with ambulation. As far as the stroke is concerned, because her hip pain will affect her before any fatiguing, she thinks she has only a 10 to 15% deficit as far as overall right-sided strength. She is able to do her ADLs. She is havingShow MoreRelatedJournal Review of a Guide to Taking a Patients History Essay1221 Words   |  5 Pagesâ€Å"A guide to taking a patient’s history,† is an article published in Nursing Standard in December 2007, written by Hillary Lloyd and Stephen Craig. The article provides an overview of the process involved in taking a patient history including factors such as; the environment, importance of following a logical order when taking the history, and communication skills. 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