Documenting a neurology round
Stroke and ward notes with the examination in a consistent order, discharge summaries, GP letters and family updates.
Day two after a minor stroke
Day two, left MCA minor stroke. Came in three hours from onset with right hand weakness and word-finding difficulty, NIHSS 3. Not thrombolysed, improving quickly.
NIHSS 1 today, mild right pronator drift only. Speech normal.
MRI, small left frontal cortical infarct. CTA no stenosis, no occlusion. Forty-eight hours on telemetry, sinus rhythm throughout.
Aspirin 100 and clopidogrel 75 for 21 days, then clopidogrel alone. Atorvastatin 80. BP 146/84, start perindopril 5, target under 130 over 80.
Echo and a seven-day Holter as an outpatient. No driving for four weeks. Stroke clinic at six weeks.
Progress
Day 2, L MCA minor ischaemic stroke. Presented 3 h from onset, NIHSS 3. Not thrombolysed (rapidly improving).
Examination
NIHSS 1: mild R pronator drift. Speech normal.
Investigations
MRI: small L frontal cortical infarct. CTA: no stenosis or occlusion. Telemetry 48 h: sinus rhythm.
Secondary prevention
- Aspirin 100 mg and clopidogrel 75 mg for 21 days, then clopidogrel alone
- Atorvastatin 80 mg
- Perindopril 5 mg (BP 146/84), target below 130/80
Plan
- Outpatient TTE and 7-day Holter
- No driving for 4 weeks
- Stroke clinic at 6 weeks
The examination recorded the same way each day
The NIHSS and the focal signs are dictated in the same order on each round, so the progress notes can be read down the admission as a trend. The discharge summary carries the antiplatelet switch date and the driving restriction with its end date, which the GP letter repeats.
Letters
- Discharge summary and GP letter
- The stroke, the investigations, the antithrombotic plan with dates, BP and lipid targets, and the outstanding Holter.
- Family update
- What happened, what is being done to prevent another stroke and the warning signs that mean calling 000.
