Ward Round Note

• Dr A. Patel, Neurology ST5

Presenting Complaints

• Acute onset right-sided weakness and expressive dysphasia

Diagnoses

• Left MCA territory ischaemic stroke
• Aspiration pneumonia

Subjective

• Day 3 admission. Pt reports slight improvement in R arm movement. Tolerating thickened fluids without coughing. Sleep satisfactory.
• PMH: HTN, AF, T2DM, previous lap cholecystectomy (2018)
• DH: apixaban 5 mg PO BD (currently held), ramipril 5 mg PO OD, metformin 1,000 mg PO BD, atorvastatin 80 mg PO ON
• SH: Lives with spouse in a two-storey house. Independent ADLs at baseline. Ex-smoker (20 pack-years), minimal EtOH.
• Allergies: Penicillin (rash)

Objective

• Obs: Temp 37.2 °C, HR 78 bpm (irreg), BP 138/82 mmHg, RR 16/min, SpO2 96 % on RA. O/E: Alert, GCS 14/15 (E4 V4 M6). Expressive dysphasia persists, follows 1-step commands. R facial droop. Tone normal. Power: RUL 3/5, RLL 4/5, L side 5/5. Chest: coarse crepitations R base.
• Bloods (14/05/2024): WCC 11.2 × 10^9/L, CRP 45 mg/L, Hb 134 g/L, Plt 240 × 10^9/L, Na 138 mmol/L, K 4.1 mmol/L, Cr 82 µmol/L. MRI Head (13/05/2024): Acute infarct in L MCA territory, no haemorrhagic transformation. CXR: R basal consolidation.

Assessment

• Resolving R-sided weakness post-L MCA infarct; concurrent hospital-acquired aspiration pneumonia improving on IV therapy.
• VTE prophylaxis: IPCs in situ. Hold LMWH given acute infarct size; r/v in 48 hrs.
• Antibiotics: clarithromycin 500 mg IV BD and metronidazole 500 mg IV TID (Day 2/5).
• Indwelling devices: R forearm 20G PIVC (VIP 0, inserted 13/05/2024).
• TEP: For full active ward-based treatment. For CPR and ITU escalation if clinically indicated.
• Lifestyle: Smoking cessation reinforced, low-salt diabetic diet.
• Discharge plan: Likely requires inpatient stroke rehab; awaiting PT/OT baseline assessment.

Plan

• Continue aspirin 300 mg PO OD for 14 days, then switch back to apixaban 5 mg PO BD.
• Step down antibiotics to PO once afebrile for 24 hrs and SALT clears for oral meds.
• Continue SALT Input: remain on Level 2 fluids and Level 5 diet.
• Chase carotid Doppler US and 24-hr Holter monitor.
• Daily PT/OT review for neuro-rehab.