PROGRESS NOTE case study

PROGRESS NOTE case study: 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.

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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.

PROGRESS NOTE case study

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 Rae Sibley should be 500 words or more. Cite your reference(s) in APA format at the end of your explanation.

Type your translation of the Progress Note below. Make sure to use layman’s terms in order for Rae to understand what has occurred.

PROGRESS NOTE case study

 

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