What is the recommended SOAP (Subjective, Objective, Assessment, Plan) format for an adult stroke patient with a history of cardiovascular risk factors, such as hypertension (high blood pressure), diabetes, hyperlipidemia (elevated lipids), and atrial fibrillation, presenting with symptoms like weakness, numbness, or difficulty with speech and language?

SOAP Format for Stroke Patient

Subjective (S)

Document the precise time the patient was last known to be normal – this is the critical "time zero" for all treatment decisions 1. Interview family members, witnesses, and EMS providers to establish this timeline 1.

Chief Complaint & History of Present Illness

• Onset characteristics: Sudden weakness, numbness, facial droop, speech difficulties, vision changes, severe headache, dizziness, or loss of balance 1
• Symptom progression: Determine if symptoms are improving, stable, or worsening 1
• Associated symptoms: Chest pain, palpitations, dyspnea, headache severity 1

Cardiovascular Risk Factor History

• Hypertension: Duration, control, current medications 1
• Diabetes mellitus: Type, duration, HbA1c values, current management 1
• Hyperlipidemia: Previous lipid levels, statin use 1
• Atrial fibrillation: Known history, anticoagulation status, CHA2DS2-VASc score 1
• Previous stroke/TIA: Dates, residual deficits 1
• Smoking history: Pack-years, current status 1
• Physical activity level: Baseline functional status 1

Medications

• Current antiplatelet agents (aspirin, clopidogrel) 1
• Anticoagulation (warfarin, DOACs) and last INR if applicable 2
• Antihypertensives, statins, diabetes medications 1
• Recent phosphodiesterase-5 inhibitor use (contraindication for nitrates) 1

Objective (O)

Vital Signs

• Blood pressure: Document in both arms 1
• Heart rate and rhythm: Continuous cardiac monitoring for at least 24 hours to detect atrial fibrillation 1
• Temperature: Fever >38°C requires treatment 3
• Oxygen saturation: Maintain >94% 1

Neurological Examination

• NIHSS score: Complete standardized assessment documenting severity 1
• Level of consciousness: Alert, drowsy, obtunded 1
• Cranial nerves: Facial droop, visual fields, extraocular movements, dysarthria 1
• Motor function: Strength testing all extremities, drift testing 1
• Sensory examination: Light touch, proprioception 1
• Coordination and gait: If safe to assess 1
• Swallowing assessment: Before any oral intake to prevent aspiration 1, 3

Cardiovascular Examination

• Cardiac auscultation: Irregular rhythm suggesting atrial fibrillation, murmurs suggesting valvular disease 1
• Carotid bruits: Suggesting carotid stenosis 1
• Signs of heart failure: Elevated JVP, pulmonary crackles, peripheral edema 1

Laboratory Studies

• Complete blood count 1
• Comprehensive metabolic panel: Electrolytes, renal function, glucose 1
• Fasting lipid panel: Total cholesterol, LDL, HDL, triglycerides 1
• HbA1c: For diabetes screening and control assessment 1
• INR/PT/PTT: If on anticoagulation or considering thrombolysis 1
• ESR/CRP: For inflammatory/vasculitic causes 3

Neuroimaging

• Non-contrast CT head: Completed within 25 minutes of ED arrival, interpreted within 45 minutes to rule out hemorrhage 1
• MRI with diffusion-weighted imaging: Confirms ischemic pattern, identifies watershed distribution if present 3
• CT or MR angiography: Evaluate for large vessel occlusion, carotid stenosis, intracranial atherosclerotic disease 1, 3
• CT perfusion: May identify salvageable tissue (do not delay thrombolysis to obtain) 1

Cardiac Studies

• 12-lead ECG: Identify atrial fibrillation, acute MI, LVH 1
• Continuous telemetry: Minimum 24 hours 1, 3
• Transthoracic echocardiography: Assess for cardioembolic source, LV function, valvular disease 1
• Transesophageal echocardiography: If cardioembolic source suspected but not identified on TTE 1

Carotid Studies

• Carotid Doppler ultrasound: Assess for stenosis ≥50% requiring revascularization 1, 3

Assessment (A)

Primary Diagnosis

Acute ischemic stroke with specific localization (e.g., left MCA territory, watershed distribution) 1, 3

Stroke Subtype Classification

• Large artery atherosclerosis: Carotid stenosis ≥50% or intracranial atherosclerotic disease 1, 3
• Cardioembolic: Atrial fibrillation, valvular disease, LV thrombus 1
• Small vessel (lacunar): Deep penetrating artery territory 1
• Other determined etiology: Dissection, vasculitis 1
• Undetermined etiology: Cryptogenic 1

Stroke Severity

• Minor stroke: NIHSS ≤3 1
• Moderate stroke: NIHSS 4-15 1
• Severe stroke: NIHSS >15 1

Thrombolysis Eligibility

• Eligible: Symptom onset <3 hours, no hemorrhage on CT, BP <185/110 mmHg, meets NINDS criteria 1, 3
• Not eligible: Document specific exclusion criteria 1

Risk Stratification

• CHA2DS2-VASc score: Calculate for atrial fibrillation patients (score ≥2 requires anticoagulation) 1
• Stroke recurrence risk: Based on etiology and risk factor control 1

Cardiovascular Risk Factors Present

• Hypertension (target <140/90 mmHg for secondary prevention) 1
• Diabetes (target HbA1c individualized, generally <7%) 1
• Hyperlipidemia (target LDL <1.8 mmol/L or 70 mg/dL) 1
• Atrial fibrillation (requires anticoagulation unless contraindicated) 1, 2
• Carotid stenosis ≥70% (requires urgent revascularization evaluation) 3

Complications Identified or At Risk

• Hemorrhagic transformation risk 1
• Cerebral edema risk: Especially with large territorial infarcts 1, 3
• Aspiration pneumonia risk: Due to dysphagia 1
• Venous thromboembolism risk: Due to immobility 1
• Cardiac complications: MI, arrhythmias, heart failure 1
• Depression risk: Screen all patients 1
• Seizure risk 1

Plan (P)

Acute Management (First 24-48 Hours)

Blood Pressure Management

For thrombolysis candidates: Maintain BP <185/110 mmHg before and <180/105 mmHg for 24 hours after rtPA using labetalol 10-20 mg IV or nicardipine 5 mg/hr IV titrated 1

For non-thrombolysis patients: Only lower BP if systolic >220 mmHg or diastolic >120 mmHg; reduce by 15-25% in first 24 hours 1. Do NOT aggressively lower BP in watershed strokes as these require adequate perfusion pressure 3

Thrombolysis (if eligible)

• IV alteplase 0.9 mg/kg (maximum 90 mg): 10% bolus over 1 minute, remainder over 60 minutes, initiated within 3 hours of symptom onset 3
• Monitor BP every 15 minutes for 2 hours, then every 30 minutes for 6 hours, then hourly for 16 hours 1

Antiplatelet Therapy

For minor stroke (NIHSS ≤3) or high-risk TIA (ABCD2 ≥4): Dual antiplatelet therapy with aspirin 81 mg + clopidogrel 75 mg daily for 21 days, then single agent 1. Loading doses: aspirin 160-325 mg + clopidogrel 300-600 mg 1

For moderate-severe stroke or after thrombolysis: Single loading dose aspirin 160 mg after hemorrhage excluded, then aspirin 81-325 mg daily OR clopidogrel 75 mg daily 1

For intracranial atherosclerotic disease (50-99% stenosis): Aspirin 325 mg daily (NOT dual antiplatelet, NOT anticoagulation unless separate indication) 1

Anticoagulation

For atrial fibrillation: DOACs (apixaban, rivaroxaban, dabigatran, edoxaban) preferred over warfarin unless mechanical valve or moderate-severe mitral stenosis 1, 2

Warfarin dosing (if DOAC contraindicated): Target INR 2.0-3.0 for atrial fibrillation; check INR weekly during initiation, then monthly when stable 2

Timing: Generally delay anticoagulation 3-14 days after acute stroke depending on size and hemorrhage risk 1

Stroke Unit Care

• Admit to geographically defined stroke unit with specialized interdisciplinary team 3
• Transfer to ICU if critically ill or large territorial infarct at risk for malignant edema 3
• Early neurosurgical consultation for large infarcts 3

Supportive Care

• Oxygen: Maintain saturation >94% 1
• NPO status: Until swallowing assessment completed 1, 3
• IV hydration: Maintenance fluids while NPO 1
• Fever management: Treat temperature >38°C 3
• Glucose control: Avoid hypoglycemia and severe hyperglycemia 1

VTE Prophylaxis

• Intermittent pneumatic compression devices: For all patients who cannot receive anticoagulation 1, 3
• Early mobilization: When neurologically stable 1, 3

Dysphagia Management

• Formal swallowing assessment: Before any oral intake 1, 3
• Nasogastric or small-bore feeding tube: If unable to swallow safely for medication access and nutrition 1
• Dietician consultation: For nutritional needs and tube-feeding regimen 1

Secondary Prevention (Long-term)

Lipid Management

High-dose statin therapy to achieve LDL <1.8 mmol/L (70 mg/dL) or >50% reduction from baseline 1. For patients with stroke and coronary disease, target LDL <1.8 mmol/L 1

Blood Pressure Management

Target <140/90 mmHg for most patients; <140 mmHg systolic for intracranial atherosclerotic disease 1

Diabetes Management

Target HbA1c <7% for most patients; screen all stroke patients for diabetes with fasting glucose, 2-hour glucose, HbA1c, or 75g OGTT 1

Carotid Revascularization

Urgent evaluation for carotid endarterectomy or stenting if stenosis ≥70% symptomatic 3

Lifestyle Modifications

• Smoking cessation: Mandatory 1
• Physical activity: At least moderate intensity exercise 1
• Dietary modification: Mediterranean or DASH diet 1
• Weight management: If obese 1

Monitoring for Complications

Neurological Deterioration

• Repeat NIHSS: Every 4-6 hours for first 24 hours, then daily 1
• Urgent repeat CT: If neurological worsening to assess for hemorrhagic transformation or edema 1

Cardiac Monitoring

• Continuous telemetry: Minimum 24 hours, longer if arrhythmias detected 1, 3
• Serial troponins: If chest pain or ECG changes 1

Depression Screening

Screen all patients for depression with validated tool; treat if positive 1

Functional Assessment

• Physical, occupational, speech therapy evaluations: Within 24-48 hours 1
• Rehabilitation needs assessment: For discharge planning 1

Discharge Planning

Medication Reconciliation

• Antiplatelet or anticoagulation as indicated 1
• High-dose statin 1
• Antihypertensive medications to achieve target BP 1
• Diabetes medications if applicable 1

Follow-up Appointments

• Primary care: Within 7-14 days 1
• Neurology: Within 30 days 1
• Cardiology: If atrial fibrillation or cardiac complications 1
• Rehabilitation services: As needed for ongoing therapy 1

Patient and Caregiver Education

• Stroke warning signs and when to call 911 1
• Medication adherence importance 1
• Risk factor modification strategies 1
• Fall prevention if mobility impaired 1
• Aspiration precautions if dysphagia present 1