Template for plan of management (ICH)
Impression:
Acute Intracerebral Hemorrhage:
- Manifestations: ***
- Location: ***
- Presumed Etiology: ***
- PTA antithrombotics: ***
Plan:
Acute management:
- Admit to stroke unit
- Neuro-checks (q4h)
- Baseline EKG
- Basic labs: CBC,CMP, coagulation panel and troponin
- Cardene drip to target SBP (120-160)
- Acetaminophen 500mg q6h prn headache
- NPO including medications until formal speech evaluation.
- Head of bed > 30 degrees for aspiration precautions
Workup:
-CTH: ***
-CTA: ***
-MRI: ***
Rehabilitation:
-PT, OT, ST evaluation
-Stroke education and counseling
-Consulted case manager for discharge disposition
Other medical issues:
HTN: ***
DM: ***
Prophylaxis: SCDs (DVT), no anti-coagulation for at least 24h given acute intra-cerebral bleed
Patient was staffed with the stroke attending during morning rounds.