Acute Stroke And TIA Inpatient Worksheet

Name.. Age Gender (M\F ) Occupation

Presenting complain:

Loss of consciousness , Confusion, Slurred speech, Weakness(RT\LT) , Vertigo,

Unsteady gait
Analysis of presenting complain:

Associated conditions:

Abnormal movement, Transient loss of conscious, Loss of sphincter control,

Trauma
Analysis of associated condition:
.
Systemic review:.

.
Risk factors:
Duration
treatment

HTN
DM
CAD
Valvular heart
Arrhythmia
Heart failure
PVD
Smoking
Hyperlipidemia
CVA or TIA
Thrombosis else ware
other risk factors
PMH : peptic ulcer, COPD, asthma, allergy

disability degree()bedsore, DVT, aspiration pneumonia

Drug history: .
.
Socially :

care, not care

NOTES: ...........................

CLINICALLY
General conditions

Conscious oriented, Conscious disoriented, Drowsy, Coma (GCS )

Speech: aphasia ( motor\sensory)
dysarthria
Quite, irritable\ distressed\ obese, cachexic , average weight
Vital signs:BP (
)mmHg \ PULSE (
) REGULARITY (
) p\m \
RR (
)c\m
T ( ) C \ Hyperlipidemia signsCarotid
bruit ( yes, no) peripheral palsies good, week, abscent
Bedsores site (.)grade(...)
CNS : higher mental function : intact, impaired
Gaze: normal, impaired
Facial nerve: normal,impaired\ upper, lower\ RT, LT
Gag reflex: normal, impaired
Uvula: normal, deviated\RT, LT
Other cranial nerve abnormality..
Motor examination

Cerebellar signs :
test+,

Nystagmus, Fingernose test+, Rapid alternating test+, Heel shin

Romberg test+,NOTE ............

CVS
CHEST...........................................................................................................................................
ABD

NOTE:
WOURKUP
Routine investigation:

CBC, U/E/C, RBS, LFT, FASTING LIPID PROFILE, HbA1C,

PT,INR, ESR
RADIOLOGY

CT SCAN
DOUPLEX
ECHOCARDIOGRAPHY.
ECG..
NOTE:
.
PLAN OF MANAGEMENT

Observations vital signs

Diet normal, liquid, diabetic diet, low salt diet, total entral nutriention)
NGT
Volume ../24HRS
INPUT-OUTPUT CHART
Antiplatelate :
aspirin,
plavix ,
dipyridamole
Dose: .
If their C\I.

Statin
anticoagulant

type..

dose.

warfarin dose

reason of indication..
If their C\I .

Bed sore Preventive measures (Airbed, Moisture, Turning)

Therapeutic (Debridement, Dressing, Antibiotic)
Antibiotic type.dosetype..dose..
type.dose..

DVT prophylaxis (elastic stocking, heparin

typedose..)

if their C/I..

Antiepilepsy ( YES, NO)IF yes indication?.................................type.dose.

Physiotherapy
Special management
hemorrhagic CVA or increase ICP ManitolDose

Raising bedLaxative typedose. Cough

suppressant type..dose.

Stress ulcer prophylaxis typedose..

Coma O ( polymask, ventori mask) \Airway\Suction\Chest physiotherapy
Two cannulas orcentral line \ECGmonitor.
2

Blood sugar control regimen

Anti HTN ( yes, no ) ,If no why?..................................................................................

same as previous medications
same as previous with additional medication
new treatment.
NOTE:( summarize your management)