What is the management plan for a 66-year-old male with a history of Hypertension (HTN), Diabetes Mellitus (DM), and Coronary Artery Disease (CAD) admitted for acute ischemic stroke due to Right M2 occlusion, who was given Aspirin (acetylsalicylic acid) but not Tissue Plasminogen Activator (tPA) due to being outside the treatment window and not eligible for thrombectomy with a National Institutes of Health Stroke Scale (NIHSS) score of 1?

SOAP Note for 66-Year-Old Male with Acute Ischemic Stroke

Subjective

• 66-year-old male admitted for acute ischemic stroke
• Right M2 occlusion
• NIHSS score of 1 (minimal neurological deficit)
• No reported symptoms in note

Objective

• PMH: Hypertension (HTN), Diabetes Mellitus (DM), Coronary Artery Disease (CAD)
• Treatment received: ASA (aspirin)
• Not eligible for TNK (tenecteplase) due to being outside treatment window
• Not eligible for thrombectomy due to low NIHSS score of 1

Assessment

• Acute ischemic stroke due to right M2 occlusion with minimal neurological deficit
• Multiple vascular risk factors: HTN, DM, CAD
• High risk for recurrent stroke requiring aggressive secondary prevention

Plan

The management plan should focus on aggressive secondary stroke prevention with antiplatelet therapy, intensive blood pressure control to <130/80 mmHg, high-intensity statin therapy, and comprehensive risk factor modification to reduce morbidity and mortality. 1

Immediate Management:

• Continue aspirin 81-325 mg daily 1
• Monitor vital signs and neurological status (NIHSS) every 4 hours for first 24 hours
• Avoid indwelling urethral catheters unless absolutely necessary 1
• Monitor temperature and treat if >37.5°C 1
• Early mobilization if patient remains stable

Secondary Prevention:

1. Antithrombotic Therapy:

   • Continue aspirin 75-325 mg daily indefinitely 1
   • Consider dual antiplatelet therapy (aspirin plus clopidogrel) for first 21 days if high risk of recurrence 1

2. Blood Pressure Management:

   • Target BP <130/80 mmHg 1, 2
   • Start or optimize antihypertensive regimen:
     • Preferred regimen: ACE inhibitor plus thiazide diuretic 1
     • More rigorous BP control given diabetes history 1

3. Lipid Management:

   • Start high-intensity statin therapy (atorvastatin 80 mg daily) 1, 3
   • Target LDL-C <70 mg/dL (patient is very high-risk with multiple risk factors) 1
   • Obtain fasting lipid panel within 24 hours of admission 1

4. Diabetes Management:

   • Target HbA1c <7% 1
   • Continue or optimize diabetes medications
   • Monitor blood glucose levels and avoid hypoglycemia (<60 mg/dL) 1
   • Maintain glucose levels between 140-180 mg/dL during hospitalization 1

5. Lifestyle Modifications:

   • Smoking cessation counseling if applicable 1
   • Dietary counseling: low saturated fat (<7%), low cholesterol (<200 mg/day) diet 1
   • Weight management if BMI >25 kg/m² (target BMI 18.5-24.9 kg/m²) 1
   • Physical activity: 30-60 minutes of moderate activity daily or at least 3-4 times weekly 1
   • Moderate sodium restriction 1

6. Diagnostic Workup:

   • Carotid imaging to assess for carotid stenosis
   • ECG and cardiac monitoring for at least 24 hours to detect atrial fibrillation 1
   • Consider echocardiogram to evaluate for cardiac source of embolism 1
   • Complete laboratory workup: CBC, electrolytes, renal function, fasting lipids, HbA1c 1

7. Rehabilitation Assessment:

   • Early evaluation by physical, occupational, and speech therapy as needed
   • Early commencement of rehabilitation if indicated 1

8. Patient and Family Education:

   • Stroke education regarding risk factors, prevention, and recognition of stroke symptoms
   • Medication adherence counseling
   • Follow-up appointment scheduling

Follow-up:

• Neurology clinic within 2 weeks
• Primary care follow-up within 1 month for risk factor management
• Monitor medication adherence and risk factor control

Potential Pitfalls and Caveats:

• Avoid excessive BP lowering in the acute phase as this may exacerbate ischemia 1
• Monitor for hemorrhagic transformation of infarct, especially with antithrombotic therapy
• Ensure diabetes medications are adjusted appropriately to avoid hypoglycemia
• Consider patient's renal function when selecting antihypertensive medications 1
• Recognize that although NIHSS is low, aggressive secondary prevention is still crucial to prevent recurrent events 4