Nurse Practitioner Template

Stroke Consult (Nurse)

A professional Nurse Practitioner template for healthcare professionals.

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Specialty

Nurse Practitioner

Used

32 times

Type

Note

Last edited

10/2/2024

Created by

Shaneka Simmons Patterson

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About this template

This Stroke Consult template is designed for Nurse Practitioners specializing in vascular neurology. It provides a comprehensive framework for documenting patient visits related to stroke evaluation and management. The template includes sections for chief complaint, detailed history, physical examination, neurological assessment, and treatment planning. It is ideal for capturing critical information such as cranial nerve function, motor and sensory assessments, and imaging results. This template ensures thorough documentation, aiding in accurate diagnosis and effective treatment planning. It is optimized for use with AI medical scribe software like Heidi, enhancing efficiency and accuracy in clinical settings.

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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.