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.
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