Patient Note (Tom)
Tom
(Patient ID 002)
| Name: Tom | Age: 44 | Admit date: 1 week ago | MR #: 000-002 |
| Gender Identity: Male | Race: Caucasian |
Admitting diagnosis: R hemorrhagic stroke, craniotomy |
Insurance: Cigna |
| History of present illness: 44-year-old male presented with acute left sided weakness. Symptoms began suddenly around 0830. Patient reported both upper and lower left sided weakness and numbness. Patient denied history of blood thinner use. Patient denied similar episodes to this in the past. Patient was brought in as a level one stroke to the ED and CT imaging revealed a hemorrhagic stroke with midline shift. Neurosurgery was consulted and recommended craniotomy to reduce the intracranial pressure. The patient was admitted for ongoing management of his stroke. | |
| Past medical/surgical history: Hypertension |
| Social History: Lives with very supportive wife who works full time as an accountant and teenaged son. He enjoys fixing up antique cars. | |
| Employment/work/school: High school education. Currently employed in an Amazon warehouse. | |
| Prior level of function: Independent in ambulation unlimited community distances with no device. Independent with all ADLs and IADLs. Performed work duties independently including lifting up to 50 pounds from ground to shoulder height and transporting up to 50 pounds up to 50 feet. Shared financial duties and home management with wife. | |
| Living situation/environmental barriers: Lives in one-story home with 3 stairs to enter with no rail. All living spaces are on one floor. Master bedroom has attached bathroom with walk in shower with 3-inch lip. |
RASS goal -1 to 2
Art line
Peripheral IV
Central line
Blood pressure goals systolic <220 first 24 hours; <180 second 24 hours, then normotensive
Neuro checks every 4 hours
Dysphagia diet
PT/OT/ST
OOB as able
Hydralazine PRN
Labetalol PRN
Atorvastatin
Lisinopril
CT: hemorrhagic stroke R side
Hematocrit=29% (2 days ago was 26), WBC 12,500, platelets 350,000.
Temp: 98.6F
BP: 145/92
HR: 90
RR: 16
O2: 99% on room air
Disclaimer: Although the individuals in ICE videos are real patients, the exact history has been altered to protect their identities.