Subjective Data
Subjective patient data refers to data that cannot be verified by the attending doctor. It is more of patient’s opinionated information (Drake&Hutchison, 2012). Some of the subjective data reflected in the case include; They slept and woke up to the symptoms, he had a history of blindness in the right eye that lasted 5 minutes a month ago, history of bilateral leg pain which lasted 15 minutes ago while he was walking 3 months ago and the fact that he no longer takes alcohol and he no longer smokes. Only the patient knows the truth of this information hence it is subjective information.
Questions directed to the patient
In order to get a better understanding a patient’s condition, it is important to dig deeper into the patient’s history. In this case, the questions I would ask include; do you have a headache? Have you been taking your medications as prescribed? If so, have your blood pressure been well controlled? Answers to these questions would help me to better understand the condition.
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Objective Data
Objective data refers to information that is verifiable by the attending doctor (Drake&Hutchison, 2012). Some of these include ; vital signs such as Blood pressure of 195/118, Pulse Rate of 106 , Temperature of 99.8, Oxygen saturation of 97% in room air , Respiratory rate of 18 breaths per minute. Objective data also includes systemic examination findings. In this case, objective data also includes; Pupils are equal and reactive to light , Inability to turn the eyes voluntarily to the left side , Neck is soft , Jugular vein not distended , Lungs are clear , Heart sounds regular without murmurs, Abdomen is normal , Limbs are poorly perfused , Patient was alert and oriented but does not recognize that he is sick , His speech was fluent with mild dysarthria among other systemic findings.
Likely diagnosis
This patient is likely to have suffered a cerebrovascular accident of the right hemisphere judging from the presenting symptoms and the fact that his blood pressure is severely elevated
References
Drake. (2012). Hutchison's Clinical Methods,An Integrated Approach to Clinical Practice With STUDENT CONSULT Online Access,23: Hutchison's Clinical Methods. Elsevier Health Sciences.
