Module 08 lab assignment – documentation a respiratory examination | Physical Assessment | Rasmussen College System


Neurologic System Patient Case

Subjective data

Mr. Green is a 52-years-old, visiting the office today.  He’s currently experiencing headaches and blurry vision. Mr. Green has a history of stroke and hypertension. He was previously admissions for blood transfusion, and history of surgeries. He is allergic to aspirin

Palliation– Mr. Green reports, wearing his glasses help him see better.

Quality- The pain is throbbing and pounding 

Region of the pain– Pain is located in his eye.

Severity-He describes the severity of (10/ 10)

Timing– present for the last few hours.

Understanding and impact– he reported unhappy due to the pain and blurred vision affect his daily living and life activities.

Objective data

The vital signs of Mr. Green include Temperature-36.8 C, HR- 88BPM, respiratory rate- 22BPM, and BP- 168/92 mmHg. The patient is alert but confused and oriented only to person and place and not oriented to time. He has a slurred speech.

Mr. Green, cranial nerves II and VII are impaired. Others cranial nerves are intact.

Upon examining his motor skills, Mr. Green’s muscle strength in the left arm is 2/ 5 while the left leg is 3/ 5. Sensory examination to assess the sensations, including temperature, vibration, pain, and proprioception are intact. 

Actual and potential risks. 

Mr. Green has blurred vision because the assessment findings indicate that the cranial nerve II (optic nerve) is impaired. The stroke might have affected the parts of the brain which control the optic nerve and therefore causing damage to the muscles. He also has hemiplegic headaches, which are throbbing, severe, and are accompanied by confusion.

Mr. Green is at risk of facial nerve paralysis because the assessment findings indicate that the cranial nerve VII (Facial nerve) is impaired, and the patient has left lower facial droop. It can affect the ability to blink a smile and difficulty in making various facial movements (Hinkle & Cheever, 2018). It can result when any part of the facial nerve muscles is either damaged or inflamed.