Nursing Stroke Consultation Template

VASCULAR NEUROLOGY CLINIC NOTE
Chief Complaint:
The patient reports sudden onset of weakness on the right side and difficulty with speech.
History of Present Illness:
The patient is a 68-year-old male who developed sudden right-sided weakness and slurred speech about 3 hours before arrival. He denies any loss of consciousness or headache. The patient has a history of poorly controlled hypertension and hyperlipidemia.
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.