Stroke Team/Critical Care H&P

Stroke Team/Critical Care H&P

Name @NAME@ MRN @MRN@ DOB @DOB@

Chief complaint:

HPI Summary: @NAME@ is a @AGE@ @SEX@ with a PMH significant for @PMHP@ who presented to the ED at ASLMC on *** with ***.

Initial NIHSS =*** and the patient *** the bedside dysphagia screen. The last known well time was *** at . CT of the head was negative for acute intracranial findings. The patient was not given IV Alteplase, as the last known well time was greater than 4.5 hours and ***. CTA head/neck obtained which showed ***. The patient was not a candidate for intervention due to low NIHSS/pre-morbid modified rankin score/no large vessel occlusion (LVO)***. ASA 325mg was *** given in ED. EKG in ED showed ***. The patient was admitted to the Neuro ICU for further evaluation and treatment.

Denies other neuro complaints of HA, vision changes (diplopia or increased blurred vision), dizziness, lightheadedness, dysphagia, dysarthria, N/T, focal weakness, or changes in balance or gait. Pt endorses taking *** at home.

ASSESSMENT/PLAN BY SYSTEM: Neuro: Brief explanation.

  • ***Symptoms - *** Vascular Territory ***
  • Initiate stroke orders
  • Etiology of stroke: ***
  • Vascular imaging *** -Tele to assess for underlying arrhythmia
  • Echo to evaluate cardiac structures and assess for thrombus
  • Permissive HTN x24-72 hrs/SBP goal <180 x24 hours s/p IV Alteplase ***
  • Antiplatelet: On ***. (on *** PTA)
  • PT/OT/ST consulted. IPR in future as necessary.
  • Will provided patient and family with stroke education.

Pulmonary: No active issues. On room air.

  • NC to achieve SpO2 >92%
  • Smoking cessation

CV: EKG=***. Hx of HTN and HLD.

  • Permissive HTN x24-72 hrs.*** Home BP meds held.
  • Echo to evaluate cardiac structures and assess for thrombus
  • Tele to assess for a-fib
  • LDL: ***. On *** PTA. LDL goal <70 for secondary stroke prevention.

Renal: No Hx of CKD***. Current creat ***. No active issues. Making urine.

  • Monitor
  • On IVFs

GI: Failed/passed beside dysphagia in ED.

  • Maintain NPO until speech eval
  • Then advance diet as per speech

Heme: No active issues.

  • Monitor.

Endocrine: No active issues. No hx of DM

  • Monitor.
  • SSI

ID: No active issues. Afebrile.

  • Monitor

DISPOSITION: Maintain in ICU.

BEST PRACTICES:

  • VTE prophylaxis: SCDs
  • SUP: Pepcid
  • LDA: PIV
  • Nutrition: Currently NPO
  • Therapy/mobilization: Up with therapy, PT/OT

ROS:

CONSTITUTIONAL: Denies headache. EYES: Denies double or blurred vision. ENT: Denies dysphagia. CV: Denies chest discomfort or palpitations. RESPIRATORY: Denies shortness of breath or cough. GI: Denies abdominal pain/cramping or nausea/vomiting. GU: Denies dysuria. MSK: Denies joint pain. SKIN: Denies unexplained bruising. NEURO: Denies numbness or tingling. Denies weakness. Denies speech problems. Denies gait disturbances. Denies memory problems or confusion. Denies dizziness. PSYCH: Denies anxiety.

STROKE RISK FACTORS: {SLMC Stroke APP Risk Factors:165846}

@PMH@ @PSH@ @SOC@ @FAMHX@ @ALLERGY@

MEDICATIONS: @CMEDBRIEF@

VITAL SIGNS @VS@

LABS: @LASTLABX(wbc:1)@ @LASTLABX(rbc:1)@ @LASTLABX(hct:1)@ @LASTLABX(hgb:1)@ @LASTLABX(plt:1)@ @LASTLABX(sodium)@ @LASTLABX(potassium)@ @LASTLABX(chloride)@ @LASTLABX(Glucose)@ @LASTLABX(Calcium)@ @LASTLABX(CO2)@ @LASTLABX(BUN)@ @LASTLABX(CREATININE)@. @LASTLABX(ast:1)@ @LASTLABX(GPT:1)@ @LASTLABX(GGTP:1)@ @LASTLABX(ALKPT:1)@ @LASTLABX(bilirubin:1)@ @LASTLABX(inr:1)@ @LASTLABX(cholesterol)@ @LASTLABX(HDL)@ @LASTLABX(CHOHDL)@ @LASTLABX(triglyceride)@ @LASTLABX(calcldl)@ @LASTLABX(hgba1c:1)@

PHYSICAL EXAM: *** General : Alert, cooperative, no distress, appears stated age, mood/affect appropriate HEENT: Normocephalic, without obvious abnormality, atraumatic PERRLA, conjunctiva/corneas clear, EOM's intact Neck: Supple, symmetrical, trachea midline. No carotid bruit or JVD appreciated Lungs: Clear to auscultation bilaterally, respirations unlabored, without adventiticious breath sounds

Abdomen: Soft, non-tender. Normo-active bowel sounds Extremities: Warm and well perfused. No lower extremity edema. Normal development b/l Heart: Regular rate and rhythm, no murmur.

Neurological Exam: Mental Status: Alert. Oriented to person, place, and time. Recent and remote memory intact. Follows commands. Normal attention and concentration. Speech is non-dysarthric. Language is fluent. No evidence of neglect on double simultaneous stimulation. CN: II: Normal visual fields b/l when testing with unilateral stimulation in each of the four quadrants individually. Pupils 3 mm b/l constricting with appropriate accomodation III, IV,VI: Extra-ocular movements are intact in all directions of gaze with convergence. PERRLA. No nystagmus. No ptosis. V: Normal facial sensation in the V1,V2 and V3 trigem. facial distribution;

  • corneal reflex b/l VII: Facial symmetry with normal lip seal and eye closure. VIII: Bilateral hearing intact to voice. IX,X: Uvula in midline. Palate elevates symmetrically. Voice not hoarse. XI: Shoulder shrug intact bilateral XII: Tongue in midline on protrusion STRENGTH: 5/5 to bilateral upper extremities (deltoid, triceps, biceps, wrist flexion/extension, and interossei). There is no drift BUE. FFM intact. 5/5 to bilateral lower extremities (Iliopsoas, quadriceps, hamstrings, and plantar/dorsiflexion). There is no drift BLE. TONE: There is no increased tone, cogwheel rigidity, or fasciculations present. SENSATION: Symmetric and intact to pin prick and light touch. REFLEXES: 2+ to bilateral UE/LE Bilateral plantar reflexes downgoing. COORDINATION: Bilateral finger to nose and heel to shin intact without evidence of ataxia. GAIT/STANCE: Patient has a normal walk with good arm swing.

IMAGING: All imaging reviewed.

CT head IMPRESSION:

CTA head/neck IMPRESSION:

MRI Brain IMPRESSION:

Echo IMPRESSION:

Carotid US IMPRESSION:

Discussed with Dr. ***, patient, and family.

*** sign