SHADOW HEALTH NEUROLOGICAL ASSESSMENT – SAMUEL
GREEN CASE STUDY COMPREHENSIVE CASE STUDY REPORT
latest update graded A
PATIENT DEMOGRAPHICS
Characteristic Detail
Name Samuel Green
Patient ID 14138223
Age 62 years
Gender Male
Chief Complaint "My left side is numb"
Date of Assessment [Current Date]
Setting Outpatient Clinic / Neurological Examination
CHIEF COMPLAINT & HISTORY OF PRESENTING ILLNESS
Samuel Green is a 62-year-old male presenting with a chief complaint of numbness on his left
side. He states, "My left side is numb," which began approximately 6 hours ago. The patient
reports that his symptoms started suddenly while he was at home, and he has experienced
persistent left-sided numbness since onset.
Associated Symptoms:
• Facial drooping on the left side, beginning concurrently with the arm numbness
1
, • Vision problems characterized by periods of blurry vision when reading (duration:
several months)
• Occasional headaches occurring a few times per month, lasting a few hours, described as
"tight" and "throbbing" but not severe, occurring only when reading or studying
• Reports treating headaches with regular strength acetaminophen (2 tablets at a time)
Symptom Timeline:
• 6 hours prior to presentation: Onset of left arm numbness and facial drooping
• Several months: Intermittent blurry vision when reading
• 6 months: Occasional tension-type headaches when reading or studying
Denies:
• Dizziness
• Tingling
• Difficulty speaking (no slurred speech)
• Difficulty swallowing
• Fainting
• Generalized weakness
• Tremors (except as noted)
• Problems with balance (except as noted)
• Problems with coordination
• Memory loss (except short-term)
• Chest pain
• Shortness of breath
PAST MEDICAL HISTORY
Medical Conditions:
• Hypertension – diagnosed and managed
• Type 2 Diabetes Mellitus – diagnosed and managed with oral medication
2
, • Hyperlipidemia – history noted
• Constipation – chronic issue (important prodromal symptom)
Medications:
Medication Dosage Purpose
Amlodipine [Standard dose] Hypertension management
Metformin [Standard dose] Diabetes management
Acetaminophen As needed (OTC) Headache relief
Allergies: None reported
Surgical History: None reported
Social History:
• Tobacco Use: Former smoker – quit 5 years ago
• Alcohol Intake: Infrequent – last drink 3 weeks ago; no more than 2-3 drinks per sitting,
1-2 nights per week maximum
• Illicit Drug Use: Remote history of recreational marijuana smoking (reports no current
use)
• Occupation: Not specified in available data
• Living Situation: Not specified in available data
Family History:
• Denies family history of migraines
• No specific family history of Parkinson's disease mentioned
REVIEW OF SYSTEMS
Neurological System:
3
GREEN CASE STUDY COMPREHENSIVE CASE STUDY REPORT
latest update graded A
PATIENT DEMOGRAPHICS
Characteristic Detail
Name Samuel Green
Patient ID 14138223
Age 62 years
Gender Male
Chief Complaint "My left side is numb"
Date of Assessment [Current Date]
Setting Outpatient Clinic / Neurological Examination
CHIEF COMPLAINT & HISTORY OF PRESENTING ILLNESS
Samuel Green is a 62-year-old male presenting with a chief complaint of numbness on his left
side. He states, "My left side is numb," which began approximately 6 hours ago. The patient
reports that his symptoms started suddenly while he was at home, and he has experienced
persistent left-sided numbness since onset.
Associated Symptoms:
• Facial drooping on the left side, beginning concurrently with the arm numbness
1
, • Vision problems characterized by periods of blurry vision when reading (duration:
several months)
• Occasional headaches occurring a few times per month, lasting a few hours, described as
"tight" and "throbbing" but not severe, occurring only when reading or studying
• Reports treating headaches with regular strength acetaminophen (2 tablets at a time)
Symptom Timeline:
• 6 hours prior to presentation: Onset of left arm numbness and facial drooping
• Several months: Intermittent blurry vision when reading
• 6 months: Occasional tension-type headaches when reading or studying
Denies:
• Dizziness
• Tingling
• Difficulty speaking (no slurred speech)
• Difficulty swallowing
• Fainting
• Generalized weakness
• Tremors (except as noted)
• Problems with balance (except as noted)
• Problems with coordination
• Memory loss (except short-term)
• Chest pain
• Shortness of breath
PAST MEDICAL HISTORY
Medical Conditions:
• Hypertension – diagnosed and managed
• Type 2 Diabetes Mellitus – diagnosed and managed with oral medication
2
, • Hyperlipidemia – history noted
• Constipation – chronic issue (important prodromal symptom)
Medications:
Medication Dosage Purpose
Amlodipine [Standard dose] Hypertension management
Metformin [Standard dose] Diabetes management
Acetaminophen As needed (OTC) Headache relief
Allergies: None reported
Surgical History: None reported
Social History:
• Tobacco Use: Former smoker – quit 5 years ago
• Alcohol Intake: Infrequent – last drink 3 weeks ago; no more than 2-3 drinks per sitting,
1-2 nights per week maximum
• Illicit Drug Use: Remote history of recreational marijuana smoking (reports no current
use)
• Occupation: Not specified in available data
• Living Situation: Not specified in available data
Family History:
• Denies family history of migraines
• No specific family history of Parkinson's disease mentioned
REVIEW OF SYSTEMS
Neurological System:
3
