NAME: Bertha Strong
MRN: 3846196
AGE:
65 yrs
DOB: 11/05/19xx
ADM: Today
Service: Stroke Clinic
ASU Hospital
Out Patient Stroke Clinic
ASU Hospital
Out Patient Stroke Clinic
Registration Form
Patient Name: Bertha Strong
Address:
DOB: 11/05/19XX
12470 N. Deer Valley Rd.
MRN: 3846196
Glendale, AZ 85306
SSN: 001240785
Insurance: Medicare and Veterans
Benefits
Next of Kin:
Name: Jean Trimble
Policy number: 001240785
Phone number: 602-555-1900
Guarantor: Self
Address: 12470 N. Deer Valley Rd.
Glendale, AZ 85306
Race: White
Advance Directives:
Religious preference: Not stated
Living Will No
Employer: Retired
Health Care Power of Attorney No
copy on chart No
Copy on chart _____
Patient Signature:
Bertha S-.-..-
1
IPE 4/2014
NAME: Bertha Strong
MRN: 3846196
AGE:
65 yrs
DOB: 11/05/19xx
ADM: Today
Service: Stroke Clinic
ASU Hospital
Out Patient Stroke Clinic
PROGRESS NOTES
DATE/TIME
Today/0800
RN assessment
Background: Client is assessed today sitting in wheelchair with daughter at her side.
This is their first visit to the Stroke Clinic following an ischemic embolic stroke two
months ago, and was in the hospital for one week. The stroke was related to atrial
fibrillation which is now controlled. She did not receive thrombolytic therapy at the time.
She is prescribed anticoagulation medication and a beta blocker. She and her family
refused rehab unit admission. During her hospital stay she was put on a mechanical soft
diet with nectar thick liquids due to aspiration risk. She is a widow with two daughters
and a son. She has always been the dominant matriarch and is used to controlling
others. She is a Vietnam era veteran and a retired nurse.
Physical Assessment:
Respiratory: respirations even & unlabored @ 14 bpm, lung sounds clear throughout to
auscultation, oxygen saturation 95%, productive cough with deep breaths.
Cardiovascular/Skin: skin pink warm, dry & intact, mucous membranes pink & moist,
capillary refill < 3 seconds x 4 extremities heart sounds S1 & S2 with regular rhythm &
rate of 82 bpm, blood pressure 138/78 mm Hg, radial pulses strong & equal bilaterally,
pedal pulses strong & equal bilaterally, Temp 98.6 F orally.
Neurological/Musculoskeletal: alert & oriented to person, place, time & situation,
pupils equal round reactive to light @ 2 mm, no movement of left arm and leg noted.
Daughter states that patient can transfer from bed to wheelchair to toilet with use of
walker and full assistance on left side. Strong Grip on left, weak to none on right,
Strong push on left, weak on right. Moves left toes easily and identifies which toe is
being touched. No movement of right toes, looked at foot to try to identify which toe
was being touched.
Gastrointestinal/Genital/Urinary: abdomen soft round, active bowel sounds, denies
nausea or vomiting. Daughter reports difficulty with constipation even though using
stool softener and fiber supplements. Daughter states last bowel movement was 2 days
ago with hard consistency. Urine has been dark yellow, denies difficulty with urination.
Social: Currently daughter and her two children are living with the patient. Daughter
provides most of the assistance needed with activities of daily living including help with
transfers.
Management at Home: Bertha is reluctant to use a walker, fearing that she will fall
because she feels so weak and cannot control her muscles always. She is dependent
in bathing, dressing, and most aspects of personal grooming although she tries to comb
hair if encouraged. Bertha’s older daughter, Jean, is the caregiver. She has two
teenagers and has lived with her mother for the past 3 years since her divorce. She is
very devoted to her mother who supported her and her children (financially and
emotionally) until she found a job after the divorce. Jean is now finding it difficult to
balance care of her mother, work, and care of her teenagers. She fears her daughters
are having difficulties at school but does not have the time/freedom to help them. She
wishes there were more hours in her day. She thinks her mother deserves all of her
time and cannot share that care with others “because she owes Mom so much.” Jean
does not know about or use support services currently. She says she will have to quit
her job to stay with her mother.
Safety: Medication reconciliation completed. Daughter confirms discharge
medications being given as ordered. Only addition medication was a one time use of
Tylenol to assist with sleep. Daughter states that last INR was 2.6 and no change in
Coumadin dose was required.
Clinical Speech
and Swallowing
Ms. Strong was given portions of the Boston Diagnostic for Examining Aphasia-Short
Form to assess her language abilities. The following is a report of her data.
Verbal Expression
A Murphy, RN
2
IPE 4/2014
NAME: Bertha Strong
MRN: 3846196
AGE:
65 yrs
DOB: 11/05/19xx
ADM: Today
Service: Stroke Clinic
ASU Hospital
Out Patient Stroke Clinic
Evaluation
Simple social responses: 5/6 (83%)
Picture Description for “Cookie Theft” : Girl…Boy…oh no. Stool…no.no…cookies and
no. Mom.. bad…water.
Automatic sequences: 3 / 4 (75%)
Repetition: 4/7 (57%) - includes four single words and three from one short sentence
Naming: 3/6 (50%)
Auditory comprehension
Word Comprehension: Body parts -1/2; Nouns – 5.5/8; colors ½; letters 2/2; numbers 1/2: Overall =10.5/16 (65%)
Following commands: 3/15 correct (20%)
Understanding Complex ideational Material (yes/no): 5/8 (63%)
Reading
Reading: Picture-word match: 3 / 4 (75%)
Reading Comprehension- Sentence and paragraphs 2/4 (50%)
Writing:
Able to write name with non-dominant left hand. Significant perseveration on letters and
simple words. Overall writing is laborious and partly malformed but legible.
Speech assessment:
Mild dysarthria characterized by imprecision. Speech production is limited due to
language deficits but is approximately 95% intelligible. Articulation imprecision noted on
repetition tasks and word finding tasks. Voice and fluency are within functional limits.
Language assessment:
Moderate non-fluent aphasia characterized by agrammatic language consisting of
nouns and some social phrases. Significant lack of articles (the, a); verbs (fall, wash,
etc), prepositions (in, on) and grammatical morphemes ( Verb tense - ing). Ms.
Strong’s comprehension for simple, single words is moderately impaired and her ability
to follow two step directions is severely impaired. She can read some simple words but
her ability to read sentences is not functional. She can write some functional items such
as her name but she exhibits perseveration during written tasks which was not evident
during other testing. Her ability to write in response to questions rather than dictation
should be assessed.
Swallowing Assessment:
Ms. Strong and her daughter report that the patient exhibits some coughing and choking
after eating. In addition they report that food often gets pocketed and needs to be
removed from her mouth. She has a history of weight loss. There is no history of
pneumonia and no known aspiration.
Ms. Strong is currently on a regular diet with thin liquids. Her daughter reports they
need to cut things small and put a little extra gravy on some items. Ms. Strong was on
nasogastric tube feedings for 2 days post CVA. Otherwise she has tolerated PO intake
with modifications of mechanical soft texture and nectar thick liquids during her hospital
stay.
Ms. Strong needs minimal assistance with feeding as she is unable to cut her food. She
is independent with getting the food to her mouth using her non-dominant hand. Her
endurance for meals is fair and she is alert.
Ms. Strong presents with weak buccal closure characterized by the inability to sustain a
lip seal. Her tongue lateralizes to the right and she has limited strength, speed and
range. Her jaw is symmetrical as rest and she is able to maintain jaw closure when
pressure is applied. Her soft palate is symmetrical and appears WNL. No nasality is
present in her speech. Her speech is limited but her voice was judged to be mildly
breathy. Breath support is mildly compromised as she has some difficulty remaining full
upright.
Ms. Strong was given food and liquid trial to assess the quality and safety of her
3
IPE 4/2014
NAME: Bertha Strong
MRN: 3846196
AGE:
65 yrs
DOB: 11/05/19xx
ADM: Today
Service: Stroke Clinic
ASU Hospital
Out Patient Stroke Clinic
swallow. She was upright throughout the trials. She has difficulty following directions
and each direction needed to be given one at a time. Models were also necessary.
Thin Liquid Trial – Client was given 4 oz of water. She drank by herself from a cup.
She drooled some of the water. The swallow duration (introduction of bolus to
completion of pharyngeal stage was 3 seconds. She has adequate laryngeal excursion
upon swallowing. She coughed immediately after the swallow.
Nectar Liquid Trial – Client was given 4 oz of nectar thick juice. She drank by herself
from a cup. She did not drool although her lip closure was limited. The swallow duration
(introduction of bolus to completion of pharyngeal stage was 2 seconds. She has
adequate laryngeal excursion upon swallowing. No coughing or overt signs of
aspiration were noted. Client’s voice quality was good following the swallow.
Pudding/Solid food Trial- Client was given vanilla pudding. She fed herself with a
spoon. The examiner needed to hold the cup so it did not slide on the tray. The swallow
duration (introduction of bolus to completion of pharyngeal stage was 4 seconds. She
has adequate laryngeal excursion upon swallowing. No coughing or other signs of
aspiration were noted.
Moist Chicken/Solid food Trial- Client was given cut up chicken. She fed herself with a
fork. The client chewed her food for 8 seconds prior to attempting to swallow. She
struggled and produced an audible swallow. No coughing or other signs of aspiration
were noted. Upon examination of the oral cavity, chicken remained in the left lateral
sulci. She was unable to remove this with her tongue and was not aware that this food
remained.
Lettuce/Solid food Trial- Client was given some salad. She fed herself with a fork. The
client chewed her food for 8 seconds prior to attempting to swallow. She swallowed but
immediately coughed and tried to clear her throat. She stated that a piece of lettuce got
stuck. She was able to cough/clear and swallow a second time.
Nutrition
Assessment
Kelly Ingram, M.S. CCC-SLP
Age: 65
Gender: Female
Height: 61 inches
Weight: 162#
Medical Diagnosis: Ischemic Embolic Stroke Consult: Consult for nutrition assessment
ASSESSMENT
Weight History: 18# unintended weight loss last 2 months
IBW: 105 # + 11# %IBW: 154%
Activity Level: Sedentary
Medications: Coumadin, Colace, fiber supplements
Past Medical History: Ischemic Embolic Stroke, HTN
Lab Values (Date):albumin 3.8 mg/dl
Current Diet Order: Regular with thin liquids
Education Needs: Speech Therapist
Energy Needs: 1700-1900 Kcal
Protein Needs: 60-75 grams
Fluid Needs: 2600 ml/day
Energy Intake: minimal
Protein Intake: minimal
Fluid Intake: 720 ml/day
Pt complains of unintentional 18# weight loss in the last two months. Pt has right side
insufficiency unable to cut food but independent feeder. Pt complains of constipation,
last bowel movement two days ago. Taking stool softener and fiber supplements.
Sandra Mayol-Kreiser, PhD, RD, CNSC
4
IPE 4/2014
NAME: Bertha Strong
MRN: 3846196
AGE:
65 yrs
DOB: 11/05/19xx
ADM: Today
Service: Stroke Clinic
ASU Hospital
Out Patient Stroke Clinic
Social Work
Progress Notes
Initial Visit with
Bertha Strong
Referral received from nursing re: patient’s appetite decline and reduced sleep since
CVA with concerns re: patient’s mood. Met with patient and her daughter, Jean, to
assess further. Patient has communication deficits associated with CVA, yes/no
response appears somewhat unreliable, but patient is able to communicate emotions
such as sadness, worry, and concern via facial expression, gestures, and tone of voice;
responds to humor with smile. Daughter provided the bulk of information due to patient’s
communication limitations; reports patient has history of depression and PTSD
associated with military service and received mental health intervention in the past.
Daughter acknowledges patient’s lack of appetite and disrupted sleep; reports patient
has difficulty falling asleep as well as staying asleep with early morning wakening.
Daughter suspects patient’s worries, fears, and grief associated with changes
accompanying CVA are contributing to mood changes; describes patient as “down” with
episodes of tearfulness. Daughter reports some caregiver stress as well, trying to
maintain employment as well as care for mother with no outside help; notes patient
reluctant to accept in-home services due to fears of strangers in the home. Will discuss
information with interprofessional team to further develop plan of care.
PhD, MSW
5
IPE 4/2014
NAME: Bertha Strong
MRN: 3846196
AGE:
65 yrs
DOB: 11/05/19xx
ADM: Today
Service: Stroke Clinic
ASU Hospital
Out Patient Stroke Clinic
LABORATORY TEST RESULTS
DATE/TIME: Today/0800
TEST
Comprehensive Metabolic Panel:
Sodium (NA)
Potassium (K)
Chloride (CL)
CO2
Glucose
BUN
Creatinine
Calcium (Ca2+)
Total Protein
ALBUMIN
BILIRUBIN TOTAL.
AST.
ALT.
ALK PHOSPHATASE.
Complete Blood Count:
WBC
RBC
Hemoglobin
Hematocrit
Platelet count
MPV
MCV
MCH
MCHC
RDW
INR (International Normalized Range)
NORMAL VALUES
136 – 145 mEq/L
3.7 - 5.2 mEq/L
102 – 110 mmol/L
22 – 30 mmol/L
77 – 113 mg/dl
5 – 26 mg/dl
0.8 – 1.4 mg/dl
8.4 – 9.9 mg/dl
6.2 – 8.0 g/dl
3.8 - 5 mg/dl
0 – 1.2 mg/dl
8 – 40 IU/L
12 – 65 IU/L
33 – 121 IU/L
136 mEq/L
4.5 mEq/L
102 mmol/L
30 mmol/L
98 mg/dl
20 mg/dl
1.0 mg/dl
8.5 mg/dl
6.8 g/dl
3.8 mg/dl
1.0 mg/dl
32 IU/L
55 IU/L
102 IU/L
4,500-10,000 cells/mcl
Male, 4.7-6.1 million cells/mcl;
Female, 4.2-5.4 million cells/mcl
Male, 13.8-17.2 gm/dcl;
Female, 12.1-15.1 gm/dcl
Male, 40.7-50.3%;
Female, 36.1-44.3%
150,000–400,000 mm3
7.4 – 10.4 fl
80-95 femtoliter
27-31 pg/cell
32-36 gm/dl
11% - 14.5%
9,000 cells/mcl
4.8 million cells/mcl;
0.8-1.2
2.00-3.00 with anticoagulation
medication
2.8
6
IPE 4/2014
RESULTS
13.0 gm/dcl;
40.2%
332,000
9.2 fl
85 fl
29 pg/cell
34 gm/dl
12.5%
NAME: Bertha Strong
MRN: 3846196
AGE:
65 yrs
DOB: 11/05/19xx
ADM: Today
Service: Stroke Clinic
ASU Hospital
Out Patient Stroke Clinic
ASU Hospital Discharge Summary
DATE OF ADMISSION: One week before discharge
DATE OF DISCHARGE: Two months ago
ADMITTING DIAGNOSIS: R/O CVA
CHIEF COMPLAINT: Confusion and garbled speech for two days
DISCHARGE DIAGNOSES:
1.
2.
3.
4.
5.
CVA—ischemic embolic stroke (left) with Right-sided weakness
Laryngeal penetration but no aspiration
Atrial Fibrillation—new onset
Hypertension
Hx of PTSD, depression, and anxiety disorder
CONSULT Obtained: Speech Therapy
PROCEDURES Performed:
CT scan of head: Axial noncontrast computed tomography (NCCT) demonstrated diffuse
hypodensity and sulcal effacement involving the left anterior and middle cerebral artery
territories consistent with acute infarction and atrophy with diffuse old ischemic changes. The
patient is a 65-year-old female with history of garbled speech and increasing confusion for the
past two days. Impression: ischemic embolic stroke.
Barium Swallow indicates laryngeal penetration but no aspiration
BRIEF HISTORY: The patient is a 65 year old female with history of hypertension, and PTSD,
depression, and anxiety disorder related to Viet Nam war experiences. She came to the ED
after daughter noted that her speech was garbled and she seemed confused at home. The
patient was admitted to the neurology service for evaluation and treatment of a possible stroke.
PAST MEDICAL/SURGICAL HISTORY: Positive for atrial fibrillation
FAMILY HISTORY: Positive for atherosclerosis, hypertension
SOCIAL HISTORY: Widow with two daughters and a son. Never smoked. Alcohol socially. No
drugs.
ALLERGIES: NO KNOWN DRUG ALLERGIES.
REVIEW OF SYSTEMS: States no problems until time of the stroke except for hypertension
being treated with Lisinopril.
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 174/84, pulse 78, respirations 18 and saturation of 98% on room
air.
General Appearance: Overweight (180#, 5’1”), appears stated age.
7
IPE 4/2014
NAME: Bertha Strong
MRN: 3846196
AGE:
65 yrs
DOB: 11/05/19xx
ADM: Today
Service: Stroke Clinic
ASU Hospital
Out Patient Stroke Clinic
HEENT: Conjunctivae are normal.
PERRLA. EOMI.
NECK: No masses. Trachea is central. No thyromegaly.
LUNGS: Clear to auscultation and percussion bilaterally.
HEART: Irregular rhythm.
ABDOMEN: Soft, nontender, and nondistended. Bowel sounds are positive.
GENITOURINARY: Continent, Constipated
EXTREMITIES: Right-sided Upper and lower limb weakness
SKIN: Normal.
NEUROLOGIC: Cranial nerves are grossly within normal limits. No nystagmus. DTRs are
normal. Good sensation. The patient is alert, awake, and oriented x3. Speech is mildly
dysarthric. Language is limited to 1-3 words. Mild confusion.
LABORATORY DATA: WBC 8.6, hemoglobin 13.4, hematocrit 39.8, platelets 207,000, MCV
91.6, neutrophil percentage of 72.6%. Sodium 133, potassium 4.7, chloride 104. Blood urea
nitrogen of 18 and creatinine of 1.1. PT 17.4, INR 1.6, PTT 33. Glucose (fasting) 102, HbgA1c
5.6, Trig 146, Pre albumin 14.5,
HOSPITAL COURSE AND TREATMENT:
1. CVA—ischemic embolic stroke (left) with Right-sided weakness R/T new onset
Atrial Fibrillation.
2. Laryngeal penetration but no aspiration requiring Level 2 Dysphasia diet
3. Hypertension treated with Lisinopril 10 mg po daily
4. Atrial Fibrillation—Anticoagulation with Coumadin established
5. Hx of PTSD, depression, and anxiety disorder
DISCHARGE DIAGNOSIS: CVA—ischemic embolic stroke (left) with right-sided weakness
DISCHARGE DISPOSITION: The patient is discharged to home after declining Rehabilitation
Unit admission.
DISCHARGE MEDICATIONS: The patient was discharged on the following medications:
Coumadin 5 mg by mouth every evening
Lisinopril 10 mg by mouth once daily
Metoprolol XR 50 mg. by mouth once daily
Colace 100 mg by mouth once a day
Fiber supplement of choice 5 grams twice a day with 4-8 ounces of water
DISCHARGE DIET: Level 2 Dysphagia
DISCHARGE ACTIVITY: Resume activity as tolerated.
FOLLOWUP:
1. Follow up with primary provider in 2-3 days for hypertension control and
anticoagulation evaluation.
2. Appointment made for Stroke Clinic in 4 weeks.
8
IPE 4/2014
NAME: Bertha Strong
MRN: 3846196
AGE:
65 yrs
DOB: 11/05/19xx
ADM: Today
Service: Stroke Clinic
ASU Hospital
Out Patient Stroke Clinic
Ticket in: Please complete this page and bring it with you to the Interdisciplinary
Meeting.
Impressions (Statement of issues for the client and family)
Recommended Interventions
Your signature: ______________________________________________________
9
IPE 4/2014