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Shadow Health Assessment

Sally Horton — Neurological Assessment

Complete Shadow Health Neurological Assessment for Sally Horton. Ischemic stroke presentation — left facial droop, right-sided weakness, expressive aphasia, NIHSS score 8. Complete cranial nerve examination CN I-XII, NIHSS administration, Glasgow Coma Scale and CT interpretation documented. Used in GCU and Walden health assessment programs.

NIHSS Score 8Facial DroopExpressive AphasiaCT Abnormal
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Clinical Overview

Sally Horton — Neurological Assessment

Sally Horton is a 71-year-old female brought to the ER by her husband after he noticed her face drooping and her speech becoming confused approximately 90 minutes ago. She has a history of atrial fibrillation (on warfarin, last INR subtherapeutic), hypertension and Type 2 diabetes — all major stroke risk factors.

The Neurological Assessment covers the complete stroke history including time of last known well (critical for tPA eligibility), the NIHSS administration (score 8 — moderate stroke), full cranial nerve examination CN I-XII, Glasgow Coma Scale, motor strength testing, sensory assessment, cerebellar testing and CT head interpretation (hypodense area left MCA territory).

NIHSS: 8. Left facial droop. Right arm weakness 2/5. Expressive aphasia. CT: hypodense left MCA territory. Diagnosis: Ischemic stroke, left hemisphere. Stroke protocol activated, neurology and interventional radiology consulted, tPA eligibility assessed.

Primary Diagnosis: Ischemic stroke — left hemisphere, MCA territory
What is included in each document?
  • Full neurological interview transcript
  • NIHSS — all 11 items scored (score: 8)
  • Full cranial nerve examination CN I-XII
  • Glasgow Coma Scale assessment
  • Motor strength testing — bilateral
  • Sensory assessment — light touch and proprioception
  • CT head interpretation documentation
  • Stroke protocol and tPA eligibility assessment
  • EHR Provider Notes — student and model