The next step is to put together the data you have collected and work through the anatomic localization of the problem, a differential diagnosis, and management plan.
Your assessment and plan should always begin with a brief summary of the patient’s history and exam findings:
In summary, the patient is a 55-year-old woman with multiple cerebrovascular risk factors who had the acute onset of nausea, vertigo, and right hand numbness one day after chiropractic manipulation. On exam she has a right Horner’s syndrome, right-sided dysmetria, right facial and left hemibody sensory loss to pinprick, and hoarse voice.
This should always be followed by anatomic localization of the process.
These symptoms and signs localize to the right lateral medulla with involvement of the vestibular nuclei, spinal trigeminal nucleus, sympathetic fibers, spinothalamic tract, inferior cerebellar peduncle, and nucleus ambiguus.
Explain why other localizations are or aren’t possible.
The lack of tongue and limb weakness and joint position and vibration impairment indicates that the medial medulla is spared.
Next, you should put all these data together to come up with the most likely diagnosis followed by a short list of other possible diagnoses as well as how you are going to prove or disprove them.
Given the acute onset of symptoms and the fact that the signs and symptoms are all referable to a specific vascular territory, the most likely diagnosis is a stroke. The patient has multiple risk factors for vascular disease, so there may be atherosclerosis of the vertebral artery as a source for distal embolism. Alternatively, the recent chiropractic manipulation raises the possibility of a vertebral dissection with distal embolism. A cardiac source for embolism is unlikely since she has no history of cardiac disease and has a normal cardiac exam, EKG, and chest x-ray. Other processes, such as multiple sclerosis and tumor, may involve the medulla, but are much less likely based on the patient’s age and time course of symptom development. An MRI scan showing restricted diffusion in the left lateral medulla would confirm the diagnosis of acute ischemic stroke. It may also provide evidence for a vertebral dissection, though angiography would be the definitive test if a dissection were not seen on MRI.
Lastly, you should address the management plan.
The patient will be admitted to the neurology floor. She is not a candidate for t-PA because her symptom onset was more than 3 hours ago. She will be started on aspirin for stroke treatment/stroke prevention and on subcutaneous heparin for deep venous thrombosis prophylaxis since her mobility is impaired. Because of her impaired pharyngeal function, she will have a swallow evaluation before being permitted to take anything by mouth. She will have speech, occupational, and physical therapy. She will be counseled on smoking cessation. Her antihypertensive medications and insulin will be continued, and diabetes control will be assessed with accuchecks and a hemoglobin AIC. A cholesterol panel will be obtained. MRI of the brain and neck will be performed tomorrow.
You are strongly encouraged to use a problem-based plan for initial and subsequent notes. It is uncommon that a patient has only a single problem, and a problem-based plan gives you a framework for daily work.
Formatting issues
- You may write your note on standard chart paper or print it out on blank pages. Aside from the standard neurology forms, you may not create a new form for your notes.
- All notes must begin with the heading “WUMS 3 Admission Note” or “WUMS 3 Progress Note.”
- All notes must start with the date and time. If there is more than one page, number each page (“page 2/6” etc). Sign and date each page. If your signature is not easily legible, you should print your name as well.
- Correct errors with a single strikethrough and add your initials. Do not use white-out or erasures.
- Notes must be in the chart on the day of admission. It is your responsibility to have your resident review and sign each note before leaving at the end of the day.