SOAP
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
- Pre/syncope workup
- Infectious workup
- Metabolic workup
- Orthostatic Vitals QShit
- 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)
- 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)
#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
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
<Symptom>
DDx: TIA vs Recrudescence of an Old stroke vs Todds Paralysis
#TIA workup for Etiology
- 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.
- 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
Stroke (NO Intervention)
<Symptom>
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)
<Symptom>
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)
<Symptom>
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)
<Symptom>
#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)
#Secondary Stroke Prevention
- 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 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.
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
- 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
- IV Hydration (normal saline)
- 500 cc to 1L IV fluid bolus per patient tolerance
- Start 125-200 cc/hr per patient tolerance
OR
AND
AND
- 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
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
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