• Image-1455

  • Tom
    Client ID 002

  • Name:
    Tom
    Age:
    44
    Primary Diagnosis:
    R CVA, craniotomy
    Gender Identity:
    Male
    Insurance: 
    Cigna
    Pronouns:
    He/him/his
    Referring Physician: 
    Garett Lundy, MD
    Race/Ethnicity:
    White

  • 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

  • Disclaimer: Although the individuals in ICE videos are real patients, the exact history has been altered to protect their identities.

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