Stroke Consult (Nurse)

VASCULAR NEUROLOGY CLINIC NOTE Chief Complaint: The patient presents with sudden onset of right-sided weakness and difficulty speaking. History of Present Illness: The patient is a 68-year-old male who experienced sudden weakness on the right side of his body and slurred speech approximately 3 hours prior to arrival. He denies any loss of consciousness or headache. The patient has a history of hypertension and hyperlipidemia, which are poorly controlled. Past Medical History: Hypertension, Hyperlipidemia, Type 2 Diabetes Mellitus Past Surgical History: Appendectomy in 1995 Current Medications: Lisinopril 20 mg daily, Atorvastatin 40 mg daily, Metformin 500 mg twice daily Allergies: No known drug allergies Family History: Father had a stroke at age 70, Mother has hypertension Social History: The patient is a retired teacher, lives with his wife, and has a 20-pack-year smoking history but quit 10 years ago. He consumes alcohol occasionally and denies illicit drug use. PHYSICAL EXAMINATION Vital Signs: Blood pressure: 160/95 mmHg, Weight: 85 kg, BMI: 28 General: The patient appears alert but anxious, with mild right-sided facial droop. NEUROLOGICAL Mental Status: The patient is oriented to person, place, and time. Speech is slurred but comprehensible. Short-term memory is intact, and mood is appropriate. Cranial Nerves: CN I (Olfactory): Intact CN II (Optic): Visual acuity 20/30 bilaterally CN III (Oculomotor): Pupils equal, round, reactive to light CN IV (Trochlear): Intact CN V (Trigeminal): Decreased sensation on right side of face CN VI (Abducens): Intact CN VII (Facial): Right-sided facial weakness CN VIII (Vestibulocochlear): Hearing intact CN IX (Glossopharyngeal): Gag reflex present CN X (Vagus): Swallowing intact CN XI (Accessory): Shoulder shrug equal bilaterally CN XII (Hypoglossal): Tongue midline MOTOR Tone: Increased tone on the right side Power: 4/5 strength in right upper and lower extremities, 5/5 on the left Reflexes: Hyperreflexia on the right side Sensory: Decreased sensation to light touch and pinprick on the right side Coordination: Impaired finger-to-nose on the right Gait: Unable to assess due to weakness Labs: CBC and BMP within normal limits, HbA1c 7.5% Imaging: CT scan shows an acute ischemic stroke in the left middle cerebral artery territory ASSESSMENT: Acute ischemic stroke likely due to embolic event PLAN: Initiate aspirin 325 mg daily, start atorvastatin 80 mg daily, and consult with neurology for possible thrombolysis. Blood pressure goal <140/90 mmHg. Educate patient on lifestyle modifications, including smoking cessation and diet changes. Total time spent during the visit: 45 minutes Patient Instructions: Take aspirin as prescribed. Monitor blood pressure daily and report any significant changes. Follow a low-sodium, heart-healthy diet. Schedule a follow-up appointment with your primary care provider in one week.