JSKSOAP

Frequently Used Stroke/TIA Epilepsy Seizure Other

Frequently Used

ADH Notes

XX-year-old with PMHx sig for

Comes in complaining of

Last known well is

===

Recent Major Surgeries: No Recent Major Fall/Trauma: No Hx of ICH: No Antithrombotics: No anticoagulation

===

Blood Sugar: Blood Pressure: Weight: ===

Called before imaging completed, resulting in delayed assessment and recommendations

Encephalopathy

Acute Confusional State/ Acute Encephalopathy

DDx: Metabolic vs Infectious Encephalopathy (Most Likely), Acute Ischemic Stroke (Less Likely), Delirium over dementia, Syncope, Seizure/Post-Ictal

#Acute Stroke Intervention

Not a thrombolytic therapy candidate outside time window

Not a thrombolytic therapy candidate mild NON-disabling Stroke symtoms

Not a thrombolytic therapy candidate NIHSS is Zero

Not a thrombolytic therapy candidate on Direct thrombin inhibitors

Not a thrombolytic therapy candidate on Coumadin

Not a thrombectomy candidate NIHSS < 6

Not a thrombectomy candidate No LVO

STAT CTA Head and Neck to Rule out LVO (Pending - Call back for image/result review)

#Anti-thrombotics

Continue home anti-thrombotics for now

#Workup

Infectious workup

Metabolic workup

Routine MRI Brain with and without Contrast (GFR permitting)

MRA Brain without Contrast & Bilateral Carotid U/S (If CTA not completed)

Routine EEG (non-urgent, can be complete outpatient)

Order therapies as indicated (Physical, occupational &/or Speech)

#Continuity of Care

Inpatient Neurology (local vs Tele)

Close outpatient Neurology F/U

#Significant concern for Seizure (Start Prophylaxis)

Ativan 2 mg under supervision of in-house provider

Keppra 3000 mg load IV x 1 now (60 mg/kg Load; do not exceed 4000 mg)

Cont Keppra 750 mg BID (Continue for 90 days, to be discontinued by outpatient Neurologist)

#Patient and Public Safety

Seizure/Episode Precautions and Education:

Advise the following to the patient when experiencing Lucid: refrain from operating machinery, being unsupervised around heights or large bodies of water. Avoid situations where harm could occur if a seizure were to happen. Seek medical assistance if a seizure lasts longer than 5 minutes, or if multiple seizures occur without a return to cognitive baseline.
Additionally, advise the patient about state laws that require them to be seizure/episode-free for at least six (6) months (the duration may be longer in some states) before operating vehicles.

Dizziness, Unsteady Gait

# Dizziness, Unsteady Gait

DDx: BPPV (Most Likely), Acute Ischemic Stroke (less likely), Drug side-effect, Recrudescence of an Old stroke, pre-syncope

Stroke Rule Out: Given his risk factors and age, we need to rule out a stroke with an MR Brain without contrast before discharge.

#Acute Stroke Intervention

Not a thrombolytic therapy candidate outside time window

Not a thrombolytic therapy candidate mild NON-disabling Stroke symptoms

Not a thrombolytic therapy candidate NIHSS is Zero

Not a thrombolytic therapy candidate on Direct thrombin inhibitors

Not a thrombolytic therapy candidate on Coumadin

Not a thrombectomy candidate NIHSS < 6

Not a thrombectomy candidate No LVO

#Stroke Ruleout

MR Brain without contrast

#Anti-thrombotics

Continue home anti-thrombotics for now

#Workup

Pre/Syncope workup

Infectious Workup

Metabolic Workup

Orthostatic Vitals twice daily (every shift)

#BPPV

Epley Maneuver

Meclizine as needed

Antiemetic as needed

Vestibular physical therapy

Conduct fall risk assessment before discharge

#Continuity of Care

Close outpatient Neurology F/U

Close outpatient PCP F/U

Bells Palsy

#Bells Palsy

Complete Facial Palsy upper and Lower palsy

prednisone 60 mg/day for one week

valacyclovir 1000 mg three times daily for one week

If does not show improvement in 3-5 days f/u with PCP right away

#Continuity of Care

Outpatient Neurology F/u

Outpatient PCP F/u

Eye patch for sleep

Artifical tears as needed

Order therapies as indicated (Physical, occupational &/or Speech)

Bilateral Lower Ext weakness

MR Lumbar Spine w/wo Con

MR Thoracic Spine w/wo Con

Neurosurgical Evaluation may be needed after Spine MR completed

CBC, CMP, TSH, T3, T4, Folate, HgbAlc, Vitamins Bl, B2, B6, B12, MMA, Homocysteine, Vitamin D, Serum ferritin, Lactate, pyruvate, Carnitine and acyl-carnitine levels, CoQlO level, ANA, RF, ENA, ESR, CRP, Serum copper, serum or whole blood zinc, ANCA, LFT, HIV, Hepatitis panel, DDx: TIA vs Recrudescence of an Old stroke vs Stroke vs Todds vs Functional

EMG/NCS Outpatient

Lumbar Puncture and CSF Analysis: Looking for Cytoalbuminologic dissociation

Cell Count, Protein, Glucose Tube #1 and #4
Meningitis/Encephalitis Panel
Bacterial and Fungal Gram Stain and Culture

Order therapies as indicated (Physical, occupational &/or Speech)

Stroke/TIA

Neurocritical Care Note

Critical Care Note

Other Epic Notes

History

LKW: ***

CC: ***

*** w/ PMhx sig for ***. Come in complaining of ***; patient was last seen normal at ***. Patient is currently taking *** <aspirin, plavix, warfarin, eliquis>

No recent Major Fall or trauma

No recent Major surgical intervention

No recent nausea, vomiting, fever, chills, cough, Flu-like symptoms.

No recent neck manipulation or chiropractic maneuver

Review of Systems

Review of Systems:

Neurological: Negative, except as described in the HPI/PMH. Cardiac: Negative, except as described in the HPI/PMH. Respiratory: Negative, except as described in the HPI/PMH. Gastrointestinal: Negative, except as described in the HPI/PMH. Genitourinary: Negative, except as described in the HPI/PMH. Musculoskeletal: Negative, except as described in the HPI/PMH. Integument: Negative, except as described in the HPI/PMH. Hematological: Negative, except as described in the HPI/PMH. Constitutional: Negative, except as described in the HPI/PMH. Psychological: Negative, except as described in the HPI/PMH.

Review of Systems Constitutional: No weight loss, fever, chills, weakness or fatigue. HEENT: No visual loss, blurred vision, double vision or yellow sclera. No hearing loss, sneezing, congestion, runny nose or sore throat. Skin: No rash or itching. Cardiovascular: No chest pain, chest pressure or chest discomfort. No palpitations or pedal edema. Respiratory: No shortness of breath, cough or sputum production. Gastrointestinal: No anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood in stool. Genitourinary: No burning micturition. No urinary frequency or incontinence. Neurologic: No headache, dizziness, syncope, unilateral weakness, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control. Musculoskeletal: No muscle pain, back pain, joint pain or stiffness. Hematologic: No bleeding or bruising. Lymphatics: No enlarged lymph nodes. Psychiatric: No depression or anxiety. Endocrine: No reports of sweating. No cold or heat intolerance. No polyuria or polydipsia.

NIHSS

NIH Stroke Scale

Select 1: Baseline, 1 hr, 6hr, 12hr, 24hr, discharge

Date:

Time:

1A: Level ofConsciousness (0-3) :

1B: Ask Month and Age (0-3) :

1C: Tell Patient To Open and Close Eyes, then Hand Grip Squeeze (0-2) :

2: Test Horizontal Extraocular Movements (0-2) :

3: Test Visual Fields (0-3) :

4: Test Facial Palsy (0-3) :

5A: Test Left Arm Motor Drift (0-4) :

5B: Test Right Arm Motor Drift (0-4) :

6A: Test Left Leg Motor Drift (0-4) :

6B: Test Right Leg Motor Drift (0-4) :

7: Test Limb Ataxia (0-2) :

8: Test Sensation (0-2) :

9: Test Language/Aphasia

10: Test Dysarthria (0-2) :

11: Test Extinction/Inattention (0-2) :

NIHSS Total =

TIA

DDx: TIA vs Recrudescence of an Old stroke vs Todds Paralysis

Routine CTA Head and neck

Routine MRI Brian without Contrast

Transthoracic echocardiogram (TTE)

CBC, BMP, Coags, HbA1C, LDL, Telemetry, EKG

#Secondary Stroke Prevention

ASA 81 now and Daily

ASA 325 now and Daily

Plavix 75 now and Daily [for 90 days ***]

High Dose Statin (Lipitor 80)

#General Medical recommendations

Liberalize SBP to less than 220 for 24 hours

Decrease BP goal by 15% daily after first 24 hours

Start DVT prophylaxis (preferably via LMWH heparin)

Order therapies as indicated (Physical, occupational &/or Speech)

#Continuity of Care

Inpatient and outpatient Neurology f/u

#P.S. Findings, Assessment/plan, recommendation and future care discussed with primary local provider

Acute Ischemic Stroke CONSULT Note

Symptom: ***

Etiology: {}

Acute Ischemic Stroke Thearpy:

NIHSS =

Out of Window

Admit to Floor vs NICU

Telemetery

Workup for cause of stroke

Acute Ischemic Stroke Work-up:

MRI Brain without Contrast

MRA Head without Contrast

MRA Neck without Contrast

Trans-thoracic Echo-cardiogram

UA, Urinary Drug Screen

HbA1c, Lipid Panel, ESR, CRP

Telemetery, EKG

CBC, CMP, Mg, PO4

PT/PTT/INR

***Acute Ischemic Stroke in Young Work-up:(If applicable)

Anticardiolipin antibodies

Lupus Anticoagulants

Protein S

Protein C

Activated Protein C resistance

Antithrombin III

Homocysteine

Fibrinogen

Antinuclear Antibody

Lipoprotein (a),

Serum Protein Electrophoresis

Hemoglobin Electrophoresis

Sickle-cell Assay

Prothrombin Mutation G20210A testing

ESR, CRP, RPR

Complement

Ischemic Stroke Risk Reduction and Management:

ASA 325mg PO QDay; First Dose STAT

Telemetry Review

Blood Pressure Control

Permissive HTN till SBP 220 or DBP 120

Don't drop BP more than 15%/Day

Keep SBP > 160

*** PRN Labetolol or Hydrlazine IV 10mg for SBP >220 or DBP > 110 if know stenosis

Hyperlipidemia

Lipid Panel

Will Treat Hyper-Lipidemia

Diabetes

HbA1c

SSI for now; will D/C if HbA1C < 6.4

***Atrial Fibrillation (USE If in Afib)

Telemetry Review DOES NOT show Afib

CHADS2VAC Score =

Speech:

Bedside Swallow Eval

Speech Therapy

Feeding & Nutrition

NPO till swallow evaluation completed

NSS 75ml/Hour

DVT:

Sub Q Lovenox 40 mg Daily

SCDs

Disposition/Discharge Planning

PT/OT Eval

Social Work Consult

Counselling

*** Smoking cessation counselling

Stroke risk factor reduction counselling

Acute Ischemic Stroke H&P Note

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.

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.

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

Stroke (NO Intervention)

DDx: TIA vs Recrudescence of an Old stroke vs Stroke vs Todds vs Functional vs Syncope induced transient Neurological deficit

#Acute Stroke Intervention

Not a thrombolytic therapy candidate outside time window

Not a thrombolytic therapy candidate mild NON-disabling Stroke symtoms

Not a thrombolytic therapy candidate NIHSS is Zero

Not a thrombolytic therapy candidate on Direct thrombin inhibitors

Not a thrombolytic therapy candidate on Coumadin

Not a thrombectomy candidate NIHSS < 6

Not a thrombectomy candidate No LVO

STAT CTA Head and Neck to Rule out LVO (Pending - Call back for image/result review

#Workup for Etiology

Routine CTA Head and neck

STAT CTA Head and neck

STAT CTPerfusion (if Available)

Routine MR Brain with and without Contrast

Routine MRA Brain without Contrast & Bilateral Carotid U/S (If CTA not completed)

Routine MRI Brian without Contrast

Transthoracic echocardiogram (TTE)

CBC, BMP, Coags, HbA1C, LDL, Telemetry, EKG

Long term cardiac monitoring

Outpatient Sleep Study for Obstructive sleep apnea

#Other Workup to consider

Pre/syncope workup

Infectious workup

Metabolic workup

Orthostatic Vitals QShit

Labs: TSH, T3, T4, Cortisol, Folate, Vitamins Bl, B2, B6, B12, MMA, Homocysteine, Vitamin D, Serum ferritin, CK, aldolase levels

Start DVT prophylaxis (preferably via LMWH heparin)

Order therapies as indicated (Physical, occupational &/or Speech)

#Secondary Stroke Prevention (SSP)

ASA 81 now and Daily

ASA 325 now and Daily

Plavix 75 now and Daily [for 90 days]

Continue Eliquis and Get Factor Xa level

High Dose Statin (Lipitor 80)

#General Medical recommendations

Liberalize SBP to less than 180 or 220 for 24 hours

Decrease BP goal by 15% daily after first 24 hours

Start DVT prophylaxis (preferably via LMWH heparin)

Order therapies as indicated (Physical, occupational &/or Speech)

#Continuity of Care

Inpatient and outpatient Neurology f/u

#P.S. Findings, Assessment/plan, recommendation and future care discussed with primary local provider

Stroke (Thrombolytic therapy only)

DDx: TIA vs Recrudescence of an Old stroke vs Todds Paralysis

#Acute Stroke Intervention

Thrombolytic therapy candidate

Thrombolytic therapy recommendation give to Dr. *** at MM/DD/YYYY @TTTT (in Military)

SBP Goal less than 180

Thrombolytic therapy Bolus (and infusion if tPA) per patient weight

Post Thrombolytic therapy precautions and monitoring per local protocol

STAT CTA Head and Neck to Rule out LVO (Pending - Call back for image/result review)

#Stroke workup for Etiology

Routine MRI Brian without Contrast

Transthoracic echocardiogram (TTE)

CBC, BMP, Coags, HbA1C, LDL, Telemetry, EKG

#Secondary Stroke Prevention

High Dose Statin (Lipitor 80)

Antithrombotics post 24 hours of tPA per local neurologist

#Continuity of Care

Inpatient and outpatient Neurology f/u

#P.S. Findings, Assessment/plan, recommendation and future care discussed with primary local provider

Stroke (Thrombolytic therapy and Thrombectomy)

DDx: TIA vs Recrudescence of an Old stroke vs Todds Paralysis

#Acute Stroke Intervention

Thrombolytic therapy candidate

Thrombolytic therapy recommendation give to Dr. *** at MM/DD/YYYY @TTTT

SBP Goal less than 180

Thrombolytic therapy Bolus (and infusion if tPA) per patient weight

Post tPA precautions and monitoring

Thrombectomy Candidate NIHSS *** and mRS ***

Transfer to Thrombectomy center via flight for life

Thrombectomy recommendation give to Dr. *** at MM/DD/YYYY @TTTT

#Stroke workup

Routine MRI Brian without Contrast

Transthoracic echocardiogram (TTE)

CBC, BMP, Coags, HbA1C, LDL, Telemetry, EKG

#Secondary Stroke Prevention

High Dose Statin (Lipitor 80)

Antithrombotics post 24 hours of tPA per local neurologist

#Continuity of Care

Inpatient and outpatient Neurology f/u

#P.S. Findings, Assessment/plan, recommendation and future care discussed with primary local provider and receiving physician at thrombectomy capable center

Stroke (Thrombectomy Only)

#Acute Stroke Intervention

Not a Thrombolytic therapy candidate outside time window

Thrombectomy Candidate NIHSS *** and mRS ***

Transfer to Thrombectomy center via flight for life

thrombectomy recommendation give to Dr. *** at MM/DD/YYYY @TTTT (in Military)

#Stroke workup

Routine MRI Brian without Contrast

Transthoracic echocardiogram (TTE)

CBC, BMP, Coags, HbA1C, LDL, Telemetry, EKG

High Dose Statin (Lipitor 80)

#Continuity of Care

Inpatient and outpatient Neurology f/u

#P.S. Findings, Assessment/plan, recommendation and future care discussed with primary local provider and receiving physician at thrombectomy capable center

Stroke Recrudescence

#Recrudescence of an Old stroke

Infectious Workup per primary/ED physician

Metabolic workup per primary/ED physician

Stroke in Young

"Stroke in Young workup" for “embolic stroke of unknown source (ESUS)” may be needed. Please re-consult Neurology once MR is completed

Vasculitis Panel

Autoimmune Panel

Paraneoplastic Panel

Hypercoagulable panel

Transesophageal Echo

Long term cardiac monitoring

CT Chest, Abdomen and Pelvis w/wo Contrast (Malignancy Protocol)

MRA (for High GFR)

Routine/STAT MRAngio Brain without contrast

Routine Bilateral Carotid Ultrasound

Stroke Outpatient Note

Name @NAME@ MRN @MRN@ DOB @DOB@ Date of service @TD@ Primary Care Physician:@PCP@

CHIEF COMPLAINT:

SUMMARY OF RECENT HOSPITALIZATION:

CURRENT CLINIC VISIT:

REVIEW OF SYSTEMS: CONSTITUTIONAL: Denies headache. EYES: Denies double or blurred vision. ENT: Denies dysphagia CV: Denies palpitations. RESPIRATORY: Denies shortness of breath. GI: Denies melena or nausea/vomiting. GU: Denies hematuria. MSK: Denies joint pain SKIN: Denies unexplained bruising. NEURO: Denies numbness, tingling, or weakness. Denies speech problems. Denies gait disturbances. Denies memory problems or confusion. Denies dizziness. PSYCH: Denies anxiety.

PAST MEDICAL HISTORY: @PMH1@ @SURGICALHX@ @ALLERGY@ @CMEDBRIEF@ @SOC@ @FAMHX@

VITAL SIGNS: @V@

PHYSICAL EXAM: General : Alert, cooperative, no distress, appears stated age, normal mood/affect HEENT: Normocephalic,without obvious abnormality, atraumatic PERRLA, conjunctiva/corneas clear, EOM's intact Neck: Supple, symmetrical, trachea midline. Lungs: Respirations unlabored

Abdomen: Non-obese. Extremities: Warm and well perfused. No lower extremity edema. Normal development b/l Heart: ***

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 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 light touch. REFLEXES: 2+ to bilateral UE/LE Bilateral plantar reflexes downgoing. COORDINATION: Bilateral finger to nose intact without evidence of ataxia. GAIT/STANCE: Patient has a normal walk with good arm swing.

REVIEW OF DIAGNOSTIC DATA: @LASTLABX(HDL)@ @LASTLABX(CALCLDL)@ @LASTLABX(CHOLESTEROL)@ @LASTLABX(TRIGLYCERIDE)@ @LASTLABX(HGBA1C)@ @LASTLABX(INR)@

PATIENT EDUCATION/PERSONAL RISK FACTOR REVIEW: ? Discussed patient specific blood pressure control *** ? <150/90: general population (no history of DM or CKD) and age greater than 60 years old ? <140/90: general population (no history of DM or CKD) and age less than 60 years old ? <140/90: any patient with history of diabetes mellitus or CKD ? Discussed most recent cholesterol values- LDL: @LASTLABX(CALCLDL)@ ? Discussed most recent HgA1C- @LASTLABX(HGBA1C)@ ? Reviewed Diet: follow a low fat, low salt, diabetic diet ? Exercise recommendations reviewed: Increase cardiovascular exercise to 3-5 times per week, for 30 plus minutes unless contraindicated ? Discussed signs and symptoms of an acute stroke and to call 911 immediately if experienced. BEFAST reviewed and patient verbalized understanding.

IMPRESSION/PLAN:

Type of stroke -Etiology: -Current symptoms: -Dates of recent hospitalization: -Antiplatelets: -Statin therapy: Goal LDL < 70 for secondary stroke prevention. Continue on *** -Last documented NIHSS: -Current NIHSS: -Last documented MRS: -Current MRS: -Risk factor modification -Follow-up Diagnostics: -Follow-up in Clinic: -Additional Orders:

Additional diagnoses

CC:

Patient Education - Acute Ischemic Stroke

PATIENT EDUCATION/PERSONAL RISK FACTOR REVIEW: Discussed patient specific blood pressure control *** 150/90: general population (no history of DM or CKD) and age greater than 60 years old 140/90: general population (no history of DM or CKD) and age less than 60 years old 140/90: any patient with history of diabetes mellitus or CKD Discussed most recent cholesterol values- LDL: @LASTLABX(CALCLDL)@ Discussed most recent HgA1C- @LASTLABX(HGBA1C)@ Reviewed Diet: follow a low fat, low salt, diabetic diet Exercise recommendations reviewed: Increase cardiovascular exercise to 3-5 times per week, for 30 plus minutes unless contraindicated Discussed signs and symptoms of an acute stroke and to call 911 immediately if experienced. BEFAST reviewed and patient verbalized understanding.

JSK - TCD

DATE OF THE STUDY: ***

HISTORY OF PRESENT ILLNESS: A ***-year-old *** with ***, blood pressure is ***, heart rate is ***, ICP ***.

TECHNICAL SUMMARY: Two Hz probe was utilized to insonate both anterior and posterior central circulation. The anterior and posterior circulation mean velocity were obtained.

ANTERIOR CIRCULATION: The left middle cerebral artery mean flow velocity is ***. The left MCA/ACA junction mean flow velocity is ***. The left anterior cerebral artery mean flow velocity is ***. The left internal carotid artery mean flow velocity is *** (LR= ***).

The right middle cerebral artery territory mean flow velocity is ***. The right MCA/ACA junction mean flow velocity is ***. The right anterior cerebral artery mean flow velocity is ***. The right internal carotid artery mean flow velocity is *** (LR=***).

POSTERIOR CIRCULATION: The left posterior cerebral artery mean flow velocity is ***. The right posterior cerebral artery mean flow velocity is ***. The left vertebral artery mean flow velocity is ***. The right vertebral artery mean flow velocity is ***. The basilar artery mean flow velocity is ***.

IMPRESSION: The vessels`mean flow velocities that were obtained are listed above.

Imaging correlation either with conventional cerebral angiogram or CT angiogram of the head is recommended if clinically indicated. For more details please refer to the original tables of the study.

Subarachnoid Hemorrhage

Aneurysmal Subarachnoid Hemorrhage - Source *** Grade: H/H *** mF *** Vasospasm (mF ***) - *** Risk Hydrocephalus - Non-obstructive

Obtain baseline EKG and Troponin - if either abnormal order TTE to assess for - Nimodipine 60 mg PO Q4 hours for 21 days

Maintain hemoglobin between 8-10 g/dl

Maintain Magnesium greater than 1.6

Maintain serum glucose < 180 using Sliding Scale Insulin

Monitor for Hyponatremia

Monitor for seizure activity

Hold antithrombotics and anticoagulants

Holding chemical DVT prophylaxis until aneurysm secured

Continue statin therapy if patient was previously taking prior to SAH

Transcranial Doppler (TCD) daily during peak vasospasm period

Monitor for symptomatic vasospasm and delayed cerebral ischemia (DCI)

Maintain Euvolemia with strict monitoring of I/Os post Bleed day 3

I/O Matching Q4 hours post Bleed day 3

EVD set at 20 cmH20 before aneurysm secured

EVD set at 15 cmH20 before aneurysm secured

Spontaneous Intracerebral Hemorrhage

Spontaneous Intracerebral Hemorrahge

**Symptom - **Localization - **Vascular Teritory Vs Cause (Aneurysm Vs HTN)

Hemorrhagic Stroke:

- Admit to ICU (Vitals Q1)

- Telemetry

- BP Monitoring

- Neuro Checks Q1 Hour

- Keep MAP < 110

(Use Hydralazine 10 mg, Labetolol 10 mg IV Q30 mins

(May Start Nicardipine Gtt 5mg/hr max dose 15mg/hr)

- Repeat CT Scan after 24 Hours

- Neurovascular Evaluation: CTA Head and Neck for vascular abnomality and aneurysm

- ESR, CRP, HbA1c, Lipid Panel, UA, UDS

- If Acute Change in Mental Status; STAT CT Brain

History of Platelet Inhibitor use in presence clinically sig brain bleed:

- Hold all anti-platelets

- Platelet Mapping

- Will consider platelet transfusion

Anticoagulation use per History:

- Warfarin/dabigatran/abxicban

- Given *** Units of FFP

- Given *** Units of Vit K

- Transfuse *** Units of FFP

- Patient is a great chance of hematoma expansion.

- Low threshold to get CT Brain in any change of exam

***Seizure Prophylaxis:(if Cortical)

- Keppra 500 mg PO BID for 7 Days

FEN

- Bedside Swallow Eval

DVT Prophylaxis

- Hold SubQ Heparin

- SCDs

Epilepsy Seizure

Epilepsy H&P

Patient: @NAME@ Bed: @ROOMBED@ Length of Stay: @RRHLOS@

Epilepsy Requesting Physician: *** Primary Neurologist: *** CC: *** Primary Diagnosis: *** HPI Summary: ***

Subjective, Overnight events and Hospital Course: *** - ***

Summary Exam: *** - ***

Assessment and Plan/Decision Making: Neurological:

***

@JSKME@

=====================

HPI Per Dr. *** on *** : "@NAME@ is a @AGE@ year-old @SEX@ with ***

Denies chest pain, abdominal pain, Nausea and vomiting."

Additional information is obtained from: EPIC records/ family member/caregiver

Onset of seizures:

Seizure Risk factors: -febrile seizures -family history of seizures -history of meningitis/ encephalitis -history of intracranial surgery -history of head trauma

Description of seizures/possible seizures: #1 -triggers -aura/warning; tongue biting, bowel/bladder incontinence -post-ictal confusion/ sleepiness/ combativeness -seizure frequency -last seizure

#2 -triggers -aura/warning; tongue biting, bowel/bladder incontinence -post-ictal confusion/ sleepiness/ combativeness -seizure frequency -last seizure

Other information regarding seizures: ictal speech, lateralized weakness

Current AEDs:

Previous AEDs and reason for stopping:

Implantable Devices or Surgeries: Previous neurologists: Previous EEGs: Previous imaging studies: History of Status Epilepticus: Driving Status: Mood: Educational/Employment Status: Current Birth control method:

=====================

COMPREHENSIVE PHYSICAL EXAM:

VITALS: Vitals with min/max:

Vital Last Value 24 Hour Range Temperature @FLOWINST(6::1)@ @FLOWSTAT(6:24::1)@ Pulse @FLOWINST(8::1)@ @FLOWSTAT(8:24::1)@ Respiratory @FLOWINST(9::1)@ @FLOWSTAT(9:24::1)@ Non-Invasive Blood Pressure @FLOWINST(5::1)@ @FLOWSTAT(5:24::1)@ Pulse Oximetry @FLOWINST(10::1)@ @FLOWSTAT(10:24::1)@ Arterial Blood Pressure @FLOWINST(301260::1)@ @FLOWSTAT(301260:24::1)@

GENERAL:  ***No apparent distress

EYES:  ***No ptosis, clear conjunctivae.  Pupil exam as in NEURO exam below

PSYCHIATRIC:
	Level of Sensorium — {conscience:123102}
	Orientation -- x {NUMBERS 0-4:108966}
NEUROLOGICAL:
	Language {jsklang:157530}
	Dysarthria {Dysarthria:155248}
	CN -- PERRLA, EOMI, Facial Droop ***
	Motor Strength -- 
	LUE {NEURO RATING SCALE 5:119244} RUE {NEURO RATING SCALE 5:119244}
	LLE {NEURO RATING SCALE 5:119244}  RLE {NEURO RATING SCALE 5:119244}
	Motor Tone -- No cogwheel ridigity

MUSCULOSKELETAL:  Motor strength & tone as in NEURO exam above
	
CARDIOVASCULAR:
	Peripheral Pulses -- ***Dorsalis pedis & posterior tibialis pulses 2+ bilaterally
	Auscultation -- ***RRR.  Normal S1 S2.  No murmur
RESPIRATORY:
	Effort -- *** Normal
	Auscultation -- ***Breath sounds clear and symmetric

ABDOMEN: 
	Palpation -- ***No tenderness or masses.  No organomegaly
	Auscultation -- *** Normal bowel sounds

SKIN:  
	Inspection --  ***No masses or lesions by inspection
	Palpation --   ***No masses or lesions by palpation

====================== ROS: {jskros:157529}

======================

Historical Data reviewed:

PAST MEDICAL HISTORY: @MEDICALHX@ @SURGICALHX@

FAMILY HISTORY: @FAMHX@

SOCIAL HISTORY: @SOCH@

ALLERGIES: @ALLERGY@

====================== Data in the EMR was reviewed either in multidisciplinary rounds or separately. All neuroimaging in current admission and relevant prior imaging were personally reviewed.

Pertinent data as follows:

----------Medication Reivew---------- CURRENT MEDICATIONS

INFUSIONS @MEDSINFUSIONS@

SCHEDULED @MEDSSCHEDULED@

PRN @MEDSPRN@

Prior to Admission Meds @PTAMEDS@

----------Neuro---------- GSC @FLOWINST(2599::1)@ LOC @FLOW(5550000028)@ Eye @FLOWINST(2600::1)@ Verbal @FLOWINST(2602::1)@ CT: @LASTIMGIMP(img1001)@ CTA Head/Neck: @LASTIMGIMP(img1061)@ MRI: @LASTIMGIMP(img2006)@ MRA Head/Neck @LASTIMGIMP(img2127)@ @LASTIMGIMP(img2125)@

----------Cardiovascular---------- Cuff BP @FLOW(5::1)@ @FLOWSTAT(5:24::1)@ Art BP @FLOW(301260::1)@ @FLOWSTAT(301260:24::1)@ Coags @LABRCNT(pt:3,inr:3,aptt:3)@ Toponins @LABRCNT(TROPONINI:3)@ @LABRCNT(CKTOTAL,CKMB,CKMBINDEX)@ Thyroid @LABRCNT(TSH)@ Lipids @LABRCNT(CHOL:3,HDL:3,LDLCALC:3,TRIG:3,CHOLHDL:3)@ ECHO: @LASTPROC(ECHO101)@ EKG: @LASTPROC(ECG1)@

----------Renal---------- @IOBRIEF@ @LABRCNT(sodium:3,potassium:3,chloride:3,co2:3,glucose:3;aniongap:3,phos:3,mg:3)@ @LABRCNT(BUN:3,CREATININE:3)@ @LABRCNT(lacta:3)@

----------Pulmonary---------- Respiratory Rate @FLOW(9::1)@ @FLOWSTAT(9:24::1)@ SpO2 (@FLOW(250026::1)@) @FLOW(10::1)@ @FLOWSTAT(10:24::1)@

@LABRCNTIP(APH:3,APCO2:3,APO2:3,ASAT:3,AHCO3:3,FIO2:3)@

@VENTSETTINGS@ RT Assessments: Sputum @FLOW(302600)@, @FLOW(302610)@, @LASTIMG(img026:1)@

----------GI---------- LFTs @LABRCNT(ALT,AST,GGT,ALKPHOS,TBILI)@ @LABRCNT(A1C)@

----------Infectious ----------

@FLOWSTAT(6:24)@ @LABRCNT(WBC:3,HGB:3,HCT:3,MCV:3,PLT:3)@ @LABRCNTIP(RESR:3,CRP:3,AST:3,GPT:3)@ @LABRCNTIP(creatinine:3,PCT:3,LACTA:3, VANCT:3)@ @LABRCNTIP(usp2g:3,uph:3,urob:3,uwbc:3,ubactr:3,unitr:3,LEUK:3,urbc:3,uwbc:3)@ Microbiology: @LASTLABX(SDES:4)@ @LASTLABX(CULT:4)@

Status Epilepticus

#Status Epilepticus

STAT CTA head and neck rule out basilar thrombosis

Ativan and intubate if necessary

Consult ICU team and transfer to NeuroICU

Start CVEEG or RapidEEG or transfer to a facility with

Metabolic workup per ED physician

Infectious workup per ED physician

Start her on Propofol, Versed or Ketamine Infusion

Keppra 3 gm IV x 1 now [60 mg/kg Load (Max 4 gm)]

Continue Keppra 1 gm BID

Inpatient and outpatient Neurology f/u

Patient will need education on seizure precautions and other restriction including driving in future

#PS. Findings, Assessment/plan, recommendation and future care discussed with primary local provider

#Patient and Public Safety

Seizure/Episode Precautions and Education:

Advise the following to the patient when experiencing Lucid: refrain from operating machinery, being unsupervised around heights or large bodies of water. Avoid situations where harm could occur if a seizure were to happen. Seek medical assistance if a seizure lasts longer than 5 minutes, or if multiple seizures occur without a return to cognitive baseline.
Additionally, advise the patient about state laws that require them to be seizure/episode-free for at least six (6) months (the duration may be longer in some states) before operating vehicles.

Witnessed/Breakthrough Seizure

#Witnessed/Breakthrough Seizure

DDx: Provoked Seizure (alcohol withdrawal***) vs New onset epilepsy

Keppra 2 gm IV x 1 now

Cont Keppra 1gm BID for 90 days. DC by outpatient Neurologist

Metabolic Workup

Infectious workup

Urine Drug Screen

Routine EEG

MR brain w/wo Contrast

Start DVT prophylaxis (preferably via LMWH heparin)

Order therapies as indicated (Physical, occupational &/or Speech)

#Continuity of Care

Inpatient and outpatient Neurology F/U

#Patient and Public Safety

Seizure/Episode Precautions and Education:

Advise the following to the patient when experiencing Lucid: refrain from operating machinery, being unsupervised around heights or large bodies of water. Avoid situations where harm could occur if a seizure were to happen. Seek medical assistance if a seizure lasts longer than 5 minutes, or if multiple seizures occur without a return to cognitive baseline.
Additionally, advise the patient about state laws that require them to be seizure/episode-free for at least six (6) months (the duration may be longer in some states) before operating vehicles.

Psychogenic Nonepileptic Seizures (PNES)

It is recommended that the patient not be treated with any medications for treatment of epileptic seizures. The patient should also follow full seizure safety precautions until these nonepileptic/psychogenic seizures are under control. Patient not to drive until event free for 6 months. If the patient has or develops other types of spells concerning for epileptic seizures, then the patient should undergo a re-evaluation to further characterize those spells. The patient to be discharged in stable condition and plan to follow-up with neurology, psychiatry and cognitive behaviour therapy.

State Driving Law Database

State Driving Laws Database

Every state regulates driver's license eligibility of persons with certain medical conditions. The most common requirement for people with epilepsy is that they be seizure free for a specific period of time and submit a physician's evaluation of their ability to drive safely.

https://www.epilepsy.com/driving-laws

Other

Complex Migraine

#Complex Migraine DDx: Migraine (Most likely); Stroke (Less likely)

#Acute Stroke Intervention

Not a thrombolytic therapy candidate outside time window

Not a thrombolytic therapy candidate mild NON-disabling Stroke symptoms

Not a thrombolytic therapy candidate NIHSS is Zero

Not a thrombolytic therapy candidate on Direct thrombin inhibitors

Not a thrombolytic therapy candidate on Coumadin

Not a thrombectomy candidate NIHSS < 6

Not a thrombectomy candidate No LVO

#Migraine Management

Migraine Cocktail with IV Hydration (may repeat upto 3 times, Q8 hrs)

Migraine Cocktail (Consider Allergy profile in choosing options below)

NSAIDs

Ketorolac 15 mg IV x 1 every 8 Hours

Triptans

Sumatriptan: Intranasal; 5 to 10 mg. Repeated 2 hourly. Do not exceed 40 mg per day

AND

Antiemetics

Metoclopromide: 10 mg IV every 8 hours
OR Prochlorperazine: 10 mg IV every 8 hours, not to exceed 40 mg per day
OR Ondansetron: 4mg ODT

AND

IV Hydration (normal saline)

500 cc to 1L IV fluid bolus per patient tolerance
Start 125-200 cc/hr per patient tolerance

Migraine Prophylaxis to be started by outpatient neurology

If symptoms improve after cocktail then ok to discharge

If symptoms do not improve then

MR Brain w/wo Contrat
Overnight observation
Neurology Consult (Local vs Tele)

Lumbar Puncture Procedure Note

Procedure: Lumbar Puncture

Indications: *** Rule out meningitis

Consent: Emergent Procedure, Consent applied -OR- Signed Consent

Anesthesia: 10 cc 1% lidocaine

Procedure: L4-L5 interspace palapated and back cleaned with betadine; patient draped in sterile fashion; 10 cc lidocaine used; 20 gauge spinal advanced til return of CSF; sent for study; Spinal needle removed and bandage placed on back after spinal needle removed

Opening Pressure: *** mm Hg Collection: *** cc collected CSF appearance: *** EBL: *** ml

Complications: None

Studies: CSF Cell count with Differential, CSF Protein CSF Glucose CSF Rapid Meningitis panel CSF culture and smear Other as clinically indicated

Post Procedure Instructions: Patient to lay flat for 3 hours after procedure If develops HA give IV fluids and caffeine drinks

Patient tolerated the procedure well.

Brain Death Determination Note

Patient Information: @NAME@ MRN: @MRN@ Age: @AGE@ DOB: @BDAY@

Etiology of Coma: *** Irreversible Cause: ***

Prerequisite Conditions: Major Electrolyte Abnormality: *** Major EndocrineAbnormality: *** Major Acid Base Abnormality: *** Toxins or Drugs: *** Hypothermia (Temp < 36): *** SBP > 100 mm Hg: *** Sedative Medications: *** Other Confounding Variables: ***

NEUROLOGIC EXAMINATION: Intubated and not sedated Commands: does not follow commands No vertical gaze or blinking to command Pupils: *** No gaze deviation or dysconjugate gaze Corneal Reflex: Absent Facial Grimace: Absent VOR: (Cold Calorics) no response of eye movements Gag/Cough: absent

Motor Exam: RUE - No movement to central and peripheral noxious stimulation LUE - No movement to central and peripheral noxious stimulation RLE - No movement to central and peripheral noxious stimulation LLE - No movement to central and peripheral noxious stimulation

Respiratory Drive: NOT overbreathing the ventilator Ventilator: Turned to pressure support without autoflow and elevated flow trigger.No respirations or diaphragmatic movement seen

Apnea Test: ***

@RESUFAST(PHART,PCO2ART,PO2ART,HCO3ART,BEART,O2SATART)@

Confirmatory Test: *** Autopsy: Discussed with next of kin and family but they declined. Medical Examiner: ***

The time of death was recorded and certified at *** on ***/***/***.

@JSKME@

Intracranial Mass

Intracranial Mass Brain Compression Cerebral Edema

DDx: Primary Brain Tumor vs Metastatic Disease vs Lymphoma vs Abscess

Decadron 4 mg IV x 1 now

Continue 2 mg IV BID

SSI and Vit D supplementation

Keppra 2 gm IV x 1 now

Cont Keppra 1 gm NBID

Neurosurgery Consult

Neurooncology Consult

Order therapies as indicated (Physical, occupational &/or Speech)

#Continuity of Care

Inpatient and outpatient Neurology f/u

#P.S. Findings, Assessment/plan, recommendation and future care discussed with primary local provider

Signature

Junaid Kalia MD

Neurology | Stroke | Epilepsy | Neurocritical Care | Neurohospitalist

JSKSOAP

Frequently Used

Stroke/TIA

Symptom: ***

Etiology: {}

Acute Ischemic Stroke Thearpy:

Acute Ischemic Stroke Work-up:

***Acute Ischemic Stroke in Young Work-up:(If applicable)

Ischemic Stroke Risk Reduction and Management:

Blood Pressure Control

Hyperlipidemia

Diabetes

***Atrial Fibrillation (USE If in Afib)

Speech:

Feeding & Nutrition

DVT:

Disposition/Discharge Planning

Counselling

Epilepsy Seizure

***

Other

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