Clinical note · #56
Hospital & observation
Patient Name: Betty Green
MRN: 56743219
Date of Admission: 09/10/2024
Date of Discharge: 09/24/2024
Attending Physician: Dr. Richard Hall
Primary Diagnosis: Ischemic stroke with left-sided weakness
Secondary Diagnosis: Hypertension, Type 2 Diabetes
Hospital Course:
Betty Green was admitted with acute ischemic stroke. She received thrombolytic therapy and recovered gradually. Although her condition improved, she continues to have significant left-sided weakness and requires rehabilitation.
Final Physical Exam:
- Vitals: BP 145/90, HR 68
- Neuro: Left-sided weakness (3/5 strength)
Discharge Medications:
- Aspirin 81 mg daily
- Amlodipine 5 mg daily
- Metformin 1000 mg twice daily
Discharge Instructions:
- Participate in physical therapy at the SNF
- Monitor blood sugar and blood pressure daily
- Report any worsening of neurological symptoms
Follow-Up:
- Neurology follow-up in 2 weeks
- Physical therapy at SNF
Discharge Condition:
Stable, requiring assistance for mobility.
Discharge Time: 50 minutes
Disposition: Transferred to SNF for rehabilitation.