ABC Medical Center 7777 North West Street, Michigan 12345 – (555) 123-4567 -----
ID: 3512369 • Letter: A
Question
ABC Medical Center
7777 North West Street, Michigan 12345 – (555) 123-4567
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PATIENT NAME: Deana Martens MEDICAL RECORD: 8888888
DATE OF BIRTH: 3/26/1947 DATE OF ADMISSION: 1/19/2015
PROGRESS NOTE
HISTORY: Deana Martens is a 67-year-old Caucasian female who was brought to the hospital via an ambulance and subsequently admitted to the hospital on 1/19/2015 for dysphasia, dysphagia, and right hemiparesis. Ms. Martens has history of HTN, and High Cholesterol. Husband states that patient is taking medication daily. No problems have been noted prior to 1 ½ hours ago when she began to show signs of right facial drooping and complained of cephalgia. Husband states the patient was unable to drink her coffee without the liquid spilling down her face. Per the husband, the patient was reaching in the cupboard for a dish, when her right arm started to fall. After sitting at the breakfast table, the patient began to rise, when she fell to the floor, and was unable to stand up without help. She showed a steady decline within minutes developing ataxia, dysphagia, and dysarthria.
OBJECTIVE FINDINGS: Physical examination shows the patient was alert, and oriented x 2. Mild confusion noted to place. Gait was not assessed at this time due to hemiparesis. Grips were unequal. Right pupil was sluggish to respond to light. Right lower extremity was flaccid. Blood pressure was 180/92 mm Hg. Pulse, 78. Respirations, 18. Temperature 98.7. Chest radiograph, Urinalysis, CBC, PTT, Basic Chemistry Panel and ABGs were obtained. ABGs showed low 02 saturation. CT scan showed negative for an intracerebral hemorrhage. A neurology consultation was obtained. Neurologist confirmed the diagnosis of an ischemic stroke after an MRI of the brain demonstrated an ischemic area of the left cerebral cortex caused by a cerebral embolism.
IMPRESSION: Hemiparesis, HTN, Ischemic Stroke
TREATMENT SUMMARY: The patient was given Alteplase 0.9 mg/kg IV infused over 1 hour for first bolus. Continued with 0.81 mg/kg as continuous infusion over 60 minutes. Mannitol was started IV post Alteplase infusion. Patient transferred to ICU. Neuro checks ordered q 2 hrs. On the second hospital day, the patient developed hypotension, N & V. Reglan given IV and normal saline was increased to 150 drops per minute for 2 hours, then titrated down to 75. After 5 hours, patient BP was within normal limits, N & V subsided. Aggrenox started one capsule bid. Third day inpatient stay was unremarkable. Patient was transferred to medical floor. PT/OT, speech therapy ordered. Neuro checks reduced to every 4 hours. No further decline noted. Fourth inpatient stay, patient responding to PT/OT well. Use of walker with one assist. Gait and grip improving. No further neurological deficits noted. Discharge planning started. Rehabilitation facility recommended for continued PT/OT and speech therapy. Family educated on treatment plan, patient transferred to extended care facility for rehabilitation. Continue antiplatelet therapy. Informed patient and family to follow-up with neurologist one week after discharge from rehab.
PART 1: Using the information provided in Progress Note above, please complete the following information.
In this Assignment, imagine you are a medical professional working at ABC Medical Center. Your patient is Mrs. Martens. Her daughter, Rae Sibley, has just arrived from Colorado. She is concerned about her mother’s well-being. You will be meeting with the patient’s daughter to update her on what has occurred during her hospital stay, the subsequent transfer to the rehabilitation facility, and a discharge plan.
Use the information from the Progress Note to update Rae Sibley on her mother’s condition. You will be translating the medical information from the report into layman’s terms in order for the patient and patient’s daughter to understand.
Please be sure use complete sentences, proper grammar, and spelling. You can use medical terms, however, you must also use layman’s terminology. Remember, it is your job to explain to the patient’s daughter what has occurred. You may need to use outside sources.
Your explanation to Raquel Sibley should be 500 words or more. Cite your reference(s) in APA format at the end of your explanation.
Explanation / Answer
According to the hospital reports.
We diagnosed that your mother had an Ischemic stroke.
Ischemic stroke occurs when the blood vessels carrying the blood to the brain are blocked.There was no haemorrage according to the reports but the blood vessel that were carrying the blood to the left side of the brain are blocked.And the ischemic stroke that she had was actually a embolic sroke i.e clot from somewhere else from the body got detached and got struck in the blood vessels supplying the left side of the brain.Thats why she was showing the symptoms of right side paralysis like as right side facial drooping,sluggishness of right pupil,right lower extremity became flaccid,dizziness,trouble speaking and walking,etc.
We started the treatment giving her blood thinners like Alteplase(it is moderately specific for fibrin-bound plasminogen,so that circulating plasminogen is lowered) that can dissolve the clot.The next day she was having a low blood pressure so we gave her the medicines for inreasing her blood pressure.Third day she started to give positive reponse to medication then we transferred her to the medical floor for physical,occupational and speech therapies.On fourth day she started responding well to physical and occupational therapy.We recommend her to use walker and then slowly her griping and gait will start improving. Rehabilitation therapy (its done so that patient start living his/her life normally as he/she was earlier) is recommended for continued physical and occupational therapy. Antiplatelet therapy will be continued so that no other clots can be formed in the body and we can rule out any further chances of any kinds of block in the vessels.
She has to come for a follow-up a week later.