Stroke Admission Form

Stroke Admission Form

Patient Information Provider of History: _______________________________________ Patient Name: ____________________________________________ Referred from: ___________________________________________

Arrival Source:

• EMS from: ______________________________________________

• Others (Specify): _______________________________________

History Acquisition Difficulty:

• Unable to obtain history due to:

  
  

  ☐ Patient unconscious

  
  

  ☐ No relatives present
  

EMS Data (if available): ___________________________________ Last Seen Normal (Time): __________ Known Onset Time: __________

Chief Complaint: __________________________________________

Present Illness: __________________________________________

Past Medical History:Underlying Diseases / Past Illness / Family Illness:☐ DM ☐ HT ☐ DLP ☐ AF ☐ CKD☐ Hx. Ischemic Stroke ☐ Hx. ICH ☐ Other: _______________

Acute DVT (Specify location): ______________________________

Antiplatelet / Anticoagulants (if any):☐ Warfarin ☐ NOAC ☐ None Last Dose (Time): ___________

History of Surgery:☐ Denies ☐ Yes (Specify): ____________________________________

Allergies (Medications, Food, Others):☐ Denies ☐ Yes (Specify): _____________________________________

Substance Use:☐ Denies ☐ Alcohol ☐ Tobacco ☐ Other (Specify): _______________ Frequency/Duration: ______________________________________

Physical Examination

General Appearance: _______________________________________

HEENT:☐ Normal ☐ Abnormal (Specify): ________________________________

Heart:☐ Normal ☐ Abnormal (Specify): ________________________________

Chest & Lungs:☐ Normal ☐ Abnormal (Specify): ________________________________

Abdomen:☐ Normal ☐ Abnormal (Specify): ________________________________

Back & Spine:☐ Normal ☐ Abnormal (Specify): ________________________________

Skin:☐ Normal ☐ Abnormal (Specify): ________________________________

Extremities:☐ Normal ☐ Abnormal (Specify): ________________________________

Neurologic Examination:

GCS: E___ V___ M___ (Total: ___)

Pupils:

• Right: ___ mm

• Left: ___ mm

Eye Position:☐ Mid-position ☐ Deviated (Specify: ________________)

Visual Fields:☐ Normal ☐ Abnormal (Specify: ______________________)

Facial Weakness:☐ No ☐ Yes (Right/Left): _____________________________

Speech Problem: ☐ None ☐ Broca’s Aphasia ☐ Wernicke’s Aphasia ☐ Global Aphasia ☐ Dysarthria (Severity: ______________)

Motor Examination:

Sensory Examination:

NIHSS Score:

• Initial Score: __________

• Current Score: __________
  

Problem List:

Diagnosis:

Investigations & Treatment Plan:

Initial Investigations (Check all that apply): ☐ CBC with Platelets ☐ PT/INR/PTT ☐ DTX: ______ mg/dL ☐ Electrolytes (Na, K, Cl), Ca, Mg, P, LFT ☐ CT Brain Emergency ☐ EKG 12-lead ☐ CXR

Management:

Oxygen Therapy: ______ L/minIV Fluids: ______ mL NSS @ ______ mL/hr

Blood Pressure Management (if BP ≥ 185/110 mmHg):

• Nicardipine/Labetalol (Dose/Titration): ______________________

rt-PA Administration:

• Candidate: ☐ Yes ☐ No (If No, reason: _____________________)

• Contraindications: ☐ Yes ☐ No

• Example Reason: “No because 5 hr from onset, patient arrived 10:30, beyond window, poor prognosis.”

rt-PA Dosing (if applicable):

• Weight: ______ kg

• Total Dose: ______ mg (0.9 mg/kg, Max 90 mg)

• Bolus (10% in 1 min): ______ mg @ __________ (Time)

• IV Drip (90% over 60 min): ______ mg

Admit to: Stroke Unit @ __________ (Time)

Physician Signature & Stamp: ________________________________ Date & Time: ______________________________________________

Nurse/Staff Notes:

Additional Instructions:

This form is for use at [Hospital Name]. Please file in the patient’s medical record and ensure all sections are completed or marked as not applicable.