Cerebrovascular accident
Age: years old
Gender:
HISTORY:
Presents with a - history of
Symptoms include:
, , , ,
Contributing factors:
no history of: , , , , ,
no use of: , ,
EXAM:
General appearance: ,
Vital signs: , BP , HR , RR , SpO2 %, Temp °
Neck: , , , c-spine
Heart: , ,
Lungs: , ,
Extremities: , , cap refill sec, pulses , ,
Neurologic:
- Mental status: , oriented to , speech
- Cranial nerves:
- Strength: except for on ,
- Sensation: to on
- Reflexes: except for on ,
- Cerebellar function: , finger-nose, rapid alternating movements, heel-shin, Romberg , Dix-Hallpike
- Gait: , tandem gait, heel walk and toe walk
ASSESSMENT:
DDx: ischemic stroke, hemorrhagic stroke, transient ischemic attack, migraine with aura, seizure, brain tumor, subdural hematoma, encephalitis, meningitis, multiple sclerosis, global transient amnesia, hypoglycemia, metabolic encephalopathy, syncope, benign positional vertigo, vestibular neuronitis, labyrinthitis, drug intoxication, posterior circulation ischemia, arterial dissection, vasculitis, hypertensive encephalopathy
PLAN:
Investigations:
- Blood work: , , , , , ,
- ECG
- CT scan of the head
- MRI of the head
- Carotid ultrasound
- Echocardiogram
Treatments:
-
-
-
-
-
- Physiotherapy
- Speech therapy
- Occupational therapy
Further care:
- Referral to neurologist
- Referral to physiatrist
- Follow-up in
- Return if symptoms worsen or if new symptoms develop such as severe headache, sudden vision changes, or sudden weakness or numbness
HISTORY: EXAM: Neurologic: ASSESSMENT: PLAN: