Docstoc

DUNDEE HEALTH CARE

Document Sample
DUNDEE HEALTH CARE Powered By Docstoc
					e2fffff1-c313-4b1b-b070-6a687bd419ab.doc Dundee Stroke Service


PERSONAL DETAILS LABEL
NAME                        CHI

                            DOB
ADDRESS                                                     SEX


Post code                                                   MARITAL STATUS

Tel


GP
& Address
       NHS Tayside Ninewells Acute Stroke Unit


         STROKE
      ADMISSION FORM
            Ward :          Consultant:



Patient’s Age =

NEXT OF KIN                                                 RELATIONSHIP
ADDRESS



Post code                                     Tel



HISTORY
You must document the ONSET of symptoms to diagnose a stroke — if the patient woke up with a stroke record the LAST
time they were normal.

DATE OF STROKE                                              TIME OF ONSET
                                    /     /                 (24 hour clock)             :

DATE OF ADMISSION TO WARD           /     /                 TIME OF ADMISSION                  N.B. If the time is less than
                                                            (24 hour clock              :      3 thours from onset
                                                                                               Thrombolysis possible



PLACE STROKE OCCURRED:

HISTORY OF STROKE
SOURCE OF HISTORY Patient / Relative / Carer / Ambulance crew / GP / Other source (specify)




Signature                                           Name                                                    Date               1
e2fffff1-c313-4b1b-b070-6a687bd419ab.doc Dundee Stroke Service




PAST MEDICAL HISTORY
Risk factors: (give dates and details if “YES”)

                                     Yes          No   Don’t Know   Details

Previous Stroke                                                ……………………………………………………………
Residual disability                                            ……………………………………………………………
TIA                                                            ……………………………………………………………
Hypertension                                                   ………………………………………………………………
Ischaemic heart disease                                        ………………………………………………………………
Other Heart disease                                            ………………………………………………………………
Peripehral Vascular Disease                                    ………………………………………………………………
Diabetes mellitus                                                  NIDDM    IDDM
                                                               ………………………………………………………………
Hyperlipidaemia                                                ………………………………………………………………

Current smoker                                                                year started.......................
                                                                              no per day..........................
Ex Smoker                                                           year stopped....................,,,……………………………

Alcohol           units per week
            ………………………………………………………………
Peptic Ulceration                                              ………………………………………………………………


Other Past Medical History




FAMILY HISTORY
Family History of... STROKE, MI, Hypertension, Angina, or PVD (specify)




OTHER Family History of note




Signature                                                 Name                                                       Date   2
e2fffff1-c313-4b1b-b070-6a687bd419ab.doc Dundee Stroke Service




Signature                                   Name                 Date   3
e2fffff1-c313-4b1b-b070-6a687bd419ab.doc Dundee Stroke Service

DRUGS ON ADMISSION to Acute Unit
Name                                       Dose               Frequency         When Started        Indication




HISTORY OF ALLERGIES or DRUG SIDE-EFFECTS

History of Problems with Aspirin, NSAIDs, Antiplatelet drugs or Warfarin:




SOCIAL HISTORY
OCCUPATION (please mention all jobs)

RETIRED

MARRIED              WIDOWED                SINGLE           DIVORCED

Does patient live alone Yes     No
Would friends or relatives be available for support? (Give details)

DESCRIPTION OF HOME

TYPE      Detached          SemiDeatched              Flat    Which Floor       Stairs Yes     No
          Residential Home             Nursing Home
          Council owned          Rented        Relative owned      Self owned




Signature                                                Name                                                Date   4
e2fffff1-c313-4b1b-b070-6a687bd419ab.doc Dundee Stroke Service



PRE-STROKE FUNCTION
                                Yes       Help   No
                                Normal           Abnormal
Can DRIVE CAR?
                                                                  Rankin Scale or Oxford Handicap scale


                                                                                      
Can USE BUS or TAXI                                   I
Can SHOP?
                                                                  Pre stroke score
Can COOK
Can do LAUNDRY                                        .
                                                                  0=Well, no symptoms
Can MANAGE FINANCES

BASIC ADLs……
                                                                  1= Minor symptoms NOT affecting lifestyle
                                Yes       Help   No
Can WALK                                                          2= Minor handicap but independent in self care
Can TRANSFER
                                                                  3= Moderate handicap- help with ADLs needed
Can MANAGE STAIRS
Can BATH (or shower)                                              4= Needs lots of help with ADLs
Can DRESS SELF
Can GROOM SELF
                                                                  5= Needing constant attention day and night
Can manage to use TOILET
                                Yes       Help   No
Is CONTINENT of URINE
Is CONTINENT of FAECES


PREVIOUS HELP

Home help        times per week........                   District Nurse   times per week.......


Day Centre     times per week....                         Cross Roads      times per week.......


Day Hospital     times per week.......                    Other Help       times per week.......




LEISURE ACTIVITIES:




Signature                                             Name                                            Date         5
e2fffff1-c313-4b1b-b070-6a687bd419ab.doc Dundee Stroke Service
EXAMINATION
GENERAL EXAMINATION
You need height and weight to calculate the thrombolysis dose


HEIGHT (m)


WEIGHT (kg)
                                     o
Temperature                              C



CVS

PULSE RATE                                   RHYTHM


                                     /
BASELINE BP:                                 The patient should have daily blood pressure recordings (lying & standing)



JVP                                          APEX BEAT


HEART SOUNDS                                 MURMURS

                               Yes           No           Comments

NECK BRUITS                                               …………………………………
PERIPHERAL PULSES                                         …………………………………
OEDEMA                                                    …………………………………
SIGNS of DVT                                              …………………………………


FUNDOSCOPY



CHEST
NORMAL Yes           No


If ABNORMAL state findings


ABDOMEN
NORMAL Yes           No


If ABNORMAL state findings




LOCOMOTOR SYSTEM
NORMAL Yes  No

If ABNORMAL state findings
Muscle wasting Yes        No                 Osteoarthiritis Yes             No          Rheumatoid arthritis Yes         No


Signature                                                       Name                                                           Date   6
e2fffff1-c313-4b1b-b070-6a687bd419ab.doc Dundee Stroke Service

NEUROLOGICAL ASSESSMENT                                                                         Handedness Right       Left
GLASGOW COMA SCALE

Eye opening                            Best motor                               Best verbal                    Total
Never               1                  None               1                     None              1
To pain             2                  Extend to pain     2                     Noises only       2
To sound            3                  Abn flex to pain   3                     Inappropriate     3
Spontaneously       4                  Flex to pain       4                     Confused          4
                                       Localises pain     5                     Normal            5
                                       Normal             6




CONSCIOUS LEVEL
Alert      Drowsy: responds to speech                                 Semi-conscious                  Unconscious


CRANIAL NERVES

                        R          L
I                                                  VII (Facial)                                       XI (Sternomastoids)
II (Pupils,Acuity)                                 Weakness?
Visual fields intact?                              Yes       No
Yes       No                                       If yes give details
If not give details                                UMN?
Cataract present?                                  Yes       No
                                                   If not give details                                XII (Tongue)
Yes       No
If not give details
Fundi
Normal       Abnormal
If abnormal give details

III/IV/VI                                                                                             Is the swallow safe?
(Eye movements)                                    VIII
Diplopia?                                          Hearing normal?                                    Ask for fromal swallowing
Yes       No                                                                                          assessment if:
                                                   Yes       No
If yes give details                                                                                    Drowsy
                                                   If not give details
Nystagmus present?                                                                                     Unable to cough
                                                   Weber?
Yes       No                                       Rinne test?                                         Loss of palatal sensation
If yes give details                                                                                    Palate notmoving
                                                                                                          properly
                                                                                                       Aspiration is suspecged
                                                   IX/X (Palatal movment)                              Unable to sit up.
V (Trigeminal)
       I                                                                                              NB Put up “Nil by Mouth”
       II                                                                                             sign and give fluids by
       III                                                                                            alternative route.


VISUOSPATIAL(e.g. Neglect, Sensory or Visual Inattention, Agnosias, etc.)
Is there evidence of visuospatial dysfunction?            Yes    No

Visual inattention?     Yes   No
Sensory inattention     Yes   No
Draw a clock face                  Copy this picture                  Patient


If not possible to test, record reason)




Signature                                                       Name                                                   Date         7
e2fffff1-c313-4b1b-b070-6a687bd419ab.doc Dundee Stroke Service
NEUROLOGICAL ASSESSMENT
LIMBS

                                 Right      Left
ARMS                                                  MRC Power
Drift                                                 0    No contraction
Fine Finger Movement                                  1    Flicker
Tone                                                  2    Active movement with gravity eliminated
MRC Power                                             3    No resistance against gravity
Shoulder                                              4    A M against gravity but reduced againast
Elbow                                                      resistance
Wrist                                                 5    Normal power
Hand
Co-ordination (Finger/Nose)
LEGS
Tone
MRC Power
Hip
Knee
Ankle
Co-ordination (Heel/Shin)

REFLEXES        Right      Left
                                                      SENSATION       Right     Left
Jaw !
                                                      Face
TJ (C7,8)
                                                      Arm
BJ (C5,6)
                                                      Leg
SJ (C5,6)
                                                      0=absent; 1=normal
Hoffman’s
KJ (L3,4)
AJ (S1,2)
                                                      TRUNCAL                 Normal    Abnormal
Plantars
                                                      CONTROL & GAIT
0=absent; 1=with potentiation; 2=normal;
                                                      Any problem?
3=increased; C=with clonus
                                                      Sit?
                                                      Stand?
PROPORIOCEPTION           Right      Left
                                                      Walk?
Fingers
Toes
0=absent; 1=reduced; 2=normal




Signature                                      Name                                      Date     8
e2fffff1-c313-4b1b-b070-6a687bd419ab.doc Dundee Stroke Service
WHERE IS THE BRAIN LESION?
Which side?

RIGHT SIDE                      LEFT SIDE            No Clear Lateralising Signs                           BOTH

How certain is the diagnosis?


Definite            Probable              Possible              TIA           Other



                           1.    Epileptic seizures + postictal               2.    Subdural haematoma (acute, chronic)
                                 deficit
                           3.    Tumour (primary, secondary)                  4.    AV Malformation
                           5.    Hyponatraemia                                6.    Hypocalcaemia
                           7.    Hepatic encephalopathy                       8.    Wernicke Korsakoff
                           9.    Hypoglycaemia                                10.   Non-ketotic hyperglycaemia
                           11.   Alcohol & drug intoxication                  12.   Head injury
                           13.   Encephalitis/cerebral abscess                14.   Hypertensive encephalopathy
                           15.   Vasculitis                                   16.   MS
                           17.   Perhiperal nerve lesion                      18.   Migraine
                           19.   Functional (hysterical,                      20.   Creutzfeld-Jakob
                                 malingering)



Which type of stroke?


Haemorrhage                                                                                                Infarction



Subarachnoid                                                                  Primary
Haemorrhage                                                                   Intracerebral Haemorrhage



  Headache, maximal in seconds, usually severe, usually occipital or retro-
  orbital.
  Duration: hours (possible minute) to weeks                                             CLINICAL SYNDROMES
  Nausea
  Vomiting                                                                               TACS= Total Anterior Circulation Stroke
  Neck stiffness
  Photophobia
  Sudden loss of consciousness                                                           PACS = Partial Anterior Circulation Stroke
  Neurological signs: None (very often)
  Meningism                                                                              POCS= Posterior Circulation Stroke
  Focal neurological signs: IIIrd nerve palsy (posterior communicating
  artery aneurysm) dysphasia, hemiparesis (AVM, intracerebral
  haematoma)                                                                             LACS= Lacunar Stroke
  Subhyaloid haemorrhage in optic fundi
  Fever                                                                                  (see next page)
  Raised blood pressure
  Limitation of straight leg raising/ Kernig's signs
  Altered consciousness




Signature                                                 Name                                                     Date       9
e2fffff1-c313-4b1b-b070-6a687bd419ab.doc Dundee Stroke Service


WHICH TYPE OF STROKE SYNDROME?
TACS (Total Anterior Circulation Stroke)
 ALL OF…
 Dense hemiparesis (flaccid)
 Visual field loss (same side as hemianopia)
 Dysphasia (if dominanat hemisphere — normally left hemisphere)
 Neglect
 Other disturabnace of cerebral function e.g. parietal lobe signs


PACS (Partial Anterior Circulation Stroke)
 ANY TWO OF…:-
 Dense hemiparesis (flaccid)
 Visual field loss (same side as hemianopia)
 Dysphasia (if dominanat hemisphere — normally left hemisphere)
 Neglect
 Other disturabnace of cerebral function e.g. parietal lobe signs
 OR Isolated disturbance of higher cerebral function alone
 OR Pure motor/sensory deficit less extensive than for LACS (e.g. monoparesis)

LACS (Lacunar Stroke)
 ANY ONE OF…
 Pure motor hemiparesis (pure motor signs alone)
 Pure sensory hemiparesis (pure sensory signs)
 Sensori-motor hmeiparesis (mixed motor/sensory signs)
 Ataxic hemiparesis (Ataxia greater than expected fro given weakness)
 Isolated movement disorder
 NO SIGNS OF ALTERED CEREBRAL FUNCTION at all

POCS (Posterior Circulation Stroke)
 ANY OF…
 Unequivocal signs of brainstem dysfunction
 Isolated hemianopia
 Cerebellar signs

DIAGNOSTIC SEQUENCE
Is it a stroke?   Is it a          What is the       Where is the      What are the        What is the   What is the
(History)         haemorrhage      site?             source            sequelae?           meachanism?   disability
                  of an infarct?   TACI? PACI?       (?embolic)        (impairment)                      and/or
                  (CT)             POCI? LACI?                                                           handicap?

IS URGENT CT SCAN NEEDED?

It is if any answer here is "YES"

                                                                                            Yes   No

    ACUTE NEUROSURGICAL EMERGENCY?
     e.g. intracranial haematoma, cerebellar infarction or haemorrhage

    ALTERNATIVE DIAGNOSIS SUSPECTED?
     e.g. subdural haematoma, cerebral abscess, meningitis

    IATROGENIC CAUSE SUSPECTED?
     e.g. if already on aspirin, warfarin or following thrombolytic therapy for MI, etc.

HAVE YOU ARRANGED THIS URGENT SCAN?


Signature                                             Name                                                Date         10
e2fffff1-c313-4b1b-b070-6a687bd419ab.doc Dundee Stroke Service
INVESTIGATIONS
    Complete investigations sheet and carryout tests not done


    Consider "Full Coagulation Assessment" on "young" STROKEs (see "Lab. tests sheet")




PRINCIPAL DIAGNOSIS:


PROBLEMS LIST
1.                                                                   2.

3.                                                                   4.

5.                                                                   6.

7.                                                                   8.

9.                                                                   10.




REHABILITATION AIMS (e.g. full independence, back to work, transferring with one etc.)




INFORMATION TO RELATIVES




TREATMENT
If it is proven to be a NON-HAEMORRHAGIC stroke:
Ensure patient is prescribed ASPIRIN (± DIPYRIDAMOLE) unless contra-indicated (specify if contra-indicated)
If ATRIAL FIBRILLATION consider WARFARIN

Record patient what advice patient has had on secondary prevention here:
smoking                              exercise                            diet

Is the patient NORMOTENSIVE? ................... If not record treatment plan here:



Is the blood glucose raised?....................................record treatment plan:



Is there a lipid abnormality?.....................................record treatment plan:




Signature                                                        Name                                  Date   11
e2fffff1-c313-4b1b-b070-6a687bd419ab.doc Dundee Stroke Service


Investigations
Routine investigations indicated in many if not most circumstances

Investigation           Result                             Normal?        Action
Blood pressure          SBP/DBP                            No Yes
                                         Target 140/90
FBC                     Hb      WBC     Platelets          No    Yes

Plasma viscosity                                           No Yes
                                                           Not required
U + Es                                                     No Yes

Glucose                                                    No Yes
                        problems if non-fasting >11.1      Not required
                        or fasting >7.8
Lipids                  Total Cholesterol                  No Yes
                        target <5.20 (<4.8 if Prev. MI)    Not required
                        HDL
                        target <2.50
                        HDL Ratio
                        target >5 (20%)
                        Triglycerides
                        target <2.30
LFTs                                                       No Yes
                                                           Not required
Calcium                                                    No Yes
                                                           Not required
Thyroid function                                           No Yes
tests                                                      Not required
Chest X ray                                                No Yes
                                                           Not required
ECG                     Rhythm
                        Rate
                        signs of IHD / LVH                 No    Yes
Carotid duplex          RICA             LICA              No    Yes

                        ?refer vasc surgery 70-99%
CT scan                                                    No Yes
                                                           Not required


Echocardiography                                           No Yes
                                                           Not required
Inflammatory            RA Latex                           No Yes
markers                 ANF                                Not required
(Age < 55 years)        Anti cardiolipin
Thrombophilia           Anti thrombin III                  No Yes
screen                  Protein S                          Not required
(Age < 50 years)        Protein C
                        Prothrombin 20210A
                        Factor VIII
                        Factor V Leiden (to Genetics)




Signature                                       Name                               Date   12
e2fffff1-c313-4b1b-b070-6a687bd419ab.doc Dundee Stroke Service
Specialist investigations
Indicated in certain circumstances

Investigation           Result                        Normal?        Action
MRI scan                                              No Yes
                                                      Not required
24 hours ECG                                          No Yes
monitor                                               Not required
Cerebral                                              No Yes
angiography                                           Not required
Gastroscopy             OGD:                          No Yes
(if history peptic                                    Not required
ulceration)             H pylori status:
                                                      No Yes
                                                      Not required
                                                      No Yes
                                                      Not required




Signature                                   Name                              Date   13
e2fffff1-c313-4b1b-b070-6a687bd419ab.doc Dundee Stroke Service
                           STROKE PATIENT INVESTIGATIONS SUMMARY
                                                    (Please record summaries of reports)

                        CXR REPORT                                                       ECG REPORT(S)
                                                                                      consider serial recordings



                     CT BRAIN REPORT                                              CAROTID VASOSCAN REPORT

                                                                                             Right I                      Left l
                                                                  Common Carotid
                                                                  INTERNAL carotid
                                                                  External carotid

    ECHO (if applicable) (Poor LV function/Thrombus/Valve                           24 HOUR TAPE (if applicable)
                           disease)



                    24 hour ABPM report                                         Thrombophilia screen (under 50s)




                                                                                         Immunology screen



                      MRI scan report                                                   Other relevant report




                                                   LABORATORY RESULTS

RESULT                            DATE                       DATE                        DATE                             DATE

PV
Hb
WCC
PLT
Na
K
Urea
Creatinine
Protein
Albumin
Bilirubin
ALT
AP
GGT
Corr. Ca
T4
TSH
Urate

CK
Trop T

Fasting GLU
Fasting CHOL
Fasting HDL
Fasting TRIGs
HDL:CHOL%
TPHA
PT (if bleed)
APTT (if bleed)
MSSU

Serial Cardiac enzyme results (if applic) Day1.......................   Day2...................... Day3................

Patients under 50yo without clear risk factors should be considered for the following tests:

Signature                                                     Name                                                                 Date   14
 e2fffff1-c313-4b1b-b070-6a687bd419ab.doc Dundee Stroke Service
THROMBOPHILIA SCREEN             IMMUNOLOGY SCREEN              BLOOD CULTURES
Antithrombin III                 ANF
Protein C                        RA
Protein S                        Anticardiolipin
Factor VIII                      ANCA
Prothrombin 20210A               Etc.

Factor V Leiden (genetics)


FASTING HOMOCYSTEINE



 Referrals

                                                       Date                 Response
 Physiotherapy               No Yes
                             Not required
 Occupational therapy        No Yes
                             Not required
 Speech & language           No Yes
 therapy                     Not required
 Dietician                   No Yes
                             Not required
 Social work                 No Yes
                             Not required
 Specialist rehabilitation   No Yes
                             Not required




 Therapy
                                                       Date/ What given     Response
 TED stockings               No Yes
                             Not required
 Aspirin (if non-            No Yes
 haemorrhagic)               Not required
 Dipyridamole (if non        No Yes
 haemorrhagic)               Not required
 Warfarin (if AF)            No Yes
                             Anti-platelets instead

                             Not required
 Blood pressure              No Yes
 lowering therapy (a la      Not required
 PROGRESS study)
 Blood pressure              No Yes
 lowering therapy            Not required
 (hypertensive)


 Blood glucose therapy       No Yes
                             Not required
 Lipid therapy               No Yes
                             Not required


 Thrombophilia screen        No Yes
                             Not required
 Signature                                      Name                                   Date   15
e2fffff1-c313-4b1b-b070-6a687bd419ab.doc Dundee Stroke Service
Autoimmune screen         No Yes
                          Not required




Signature                                   Name                 Date   16