What are the admission orders for a 63-year-old female patient with hypertension (high blood pressure), diabetes, and a history of Transient Ischemic Attack (TIA), who is allergic to Penicillin, and is currently taking Lisinopril and Metformin?

Admission Orders for 63-year-old Female with History of TIA

Primary Diagnosis: Transient Ischemic Attack (TIA)

Status/Condition: Stable

Code Status: Full Code

Allergies: Penicillin

Admit to Unit: Medical/Telemetry Unit

Activity Level: Out of bed as tolerated with assistance

Diet: Diabetic, low sodium (2000 mg/day), heart-healthy diet

IV Fluids: 0.9% Normal Saline at 50 mL/hr

Critical Drips: None required

Respiratory: Oxygen via nasal cannula at 2L/min to maintain SpO2 >94%

Medications:

For TIA management, continue antiplatelet therapy with clopidogrel 75 mg PO daily as the preferred antiplatelet agent over aspirin alone for secondary stroke prevention. 1

1. Clopidogrel 75 mg PO daily
2. Lisinopril 20 mg PO daily (continue home medication)
3. Metformin 500 mg PO twice daily (continue home medication)
4. Atorvastatin 80 mg PO daily at bedtime (high-intensity statin therapy)
5. Insulin therapy:
   • Insulin glargine 10 units SQ at bedtime
   • Insulin lispro sliding scale before meals and at bedtime:
     • BG 150-200 mg/dL: 2 units
     • BG 201-250 mg/dL: 4 units
     • BG 251-300 mg/dL: 6 units
     • BG 301-350 mg/dL: 8 units
     • BG >350 mg/dL: 10 units and notify physician

Nursing Orders:

1. Vital signs every 4 hours including neurological checks
2. Strict intake and output monitoring
3. Fingerstick blood glucose monitoring before meals and at bedtime
4. Cardiac telemetry monitoring
5. Assess for neurological changes and report immediately if present
6. Fall precautions

Follow-Up Lab Tests:

1. Complete blood count (CBC) daily
2. Basic metabolic panel (BMP) daily
3. Fasting lipid panel in morning
4. Hemoglobin A1c
5. Coagulation profile (PT/INR, PTT)

Diagnostic Testing:

1. MRI brain with diffusion-weighted imaging
2. MR angiography of head and neck
3. Carotid Doppler ultrasound
4. 12-lead ECG on admission
5. Transthoracic echocardiogram
6. 24-hour Holter monitoring

Consults:

1. Neurology consult for TIA evaluation and management
2. Cardiology consult for cardiovascular risk assessment
3. Endocrinology consult for diabetes management

Patient Education and Health Promotion:

1. Stroke warning signs and symptoms
2. Importance of medication adherence
3. Blood pressure monitoring and control
4. Diabetes management and blood glucose monitoring
5. Smoking cessation counseling (if applicable)
6. Heart-healthy diet education
7. Regular physical activity as tolerated

Discharge Planning and Required Follow-Up Care:

1. Follow-up with neurology within 1-2 weeks
2. Follow-up with primary care physician within 1 week
3. Home blood pressure monitoring
4. Medication reconciliation prior to discharge
5. Consider outpatient cardiac rehabilitation

Management Rationale:

TIA Management

The patient has a history of TIA, which puts her at high risk for recurrent stroke. According to the American Heart Association/American Stroke Association guidelines, clopidogrel is preferred over aspirin alone for secondary stroke prevention 2. The patient should be on high-intensity statin therapy regardless of baseline LDL levels to reduce the risk of recurrent stroke 2.

Blood Pressure Management

Continuing lisinopril is appropriate as ACE inhibitors are recommended first-line therapy for patients with hypertension and history of stroke/TIA 2. The target blood pressure should be <140/90 mmHg 2.

Diabetes Management

For patients with TIA and diabetes, glycemic control should be individualized with a target HbA1c ≤7% to reduce microvascular complications 2. During hospitalization, subcutaneous insulin is preferred over oral agents to ensure adequate glycemic control 2. Metformin can be continued if renal function is adequate 3.

Diagnostic Evaluation

A comprehensive diagnostic evaluation is essential to identify the etiology of TIA and guide secondary prevention strategies. This includes brain imaging, vascular studies, and cardiac evaluation to rule out cardioembolic sources 1, 4.

Common Pitfalls to Avoid:

1. Delaying antiplatelet therapy - immediate initiation is crucial for preventing early recurrent stroke
2. Inadequate blood pressure control - overly aggressive BP lowering may worsen cerebral perfusion
3. Failure to identify atrial fibrillation - would require anticoagulation instead of antiplatelet therapy
4. Overlooking carotid stenosis - may require surgical intervention if significant stenosis is present
5. Poor glycemic control - hyperglycemia worsens stroke outcomes

The management approach prioritizes immediate secondary stroke prevention with appropriate antiplatelet therapy, optimal blood pressure and lipid control, and comprehensive diagnostic evaluation to identify and address modifiable risk factors.