History of present illness:
44yo WM admitted to the hospital one week ago with c/o upper and lower L-sided weakness and numbness beginning suddenly around 0830. Denied history of blood thinner use and similar episodes to this in the past. Diagnosed with R hemorrhagic stroke with midline shift. Neurosurgery was consulted and recommended craniotomy to reduce the intracranial pressure.

Past medical/surgical history:
HTN

Marital status: Married 24 years.

Primary language: English.

Prior level of function: Independent with all ADL/IADL including driving. Shared financial duties and home management with wife.

Employment/work/school: High school education. Currently employed in an Amazon warehouse. Work duties involve lifting up to 50 pounds from ground to shoulder height and transporting up to 50 pounds up to 50 feet.

Play/leisure/interests: Enjoys fixing up antique cars.

Environmental factors: Lives with wife and teenaged son in one-story home with 3 STE, no handrails. Walk-in shower (3” ledge). No DME. Wife is very supportive and works full-time as an accountant.

OOB as able
RASS goal -1 to 2
Art line
Peripheral IV
Central line
Telemetry
Foley catheter
Sequential compression devices BLE
Pressure reducing AFO L foot
Blood pressure goals systolic <220 first 24 hours; <180 second 24 hour, then normotensive
Neuro checks every 4 hours
Aspiration precautions
Dysphagia diet
Pulse oximeter

Hydralazine PRN
Labetalol PRN
Atorvastatin
Lisinopril

CT scan: hemorrhagic stroke R side