What is the appropriate format for a case sheet for a patient with hemiplegia (acute stroke), including demographics, chief complaint, history of present illness, past medical history, medications, allergies, family and social history, review of systems, physical examination, investigations, assessment, management plan, follow‑up and documentation?

How to Write a Case Sheet for Hemiplegia (Acute Stroke)

A comprehensive case sheet for hemiplegia must document time-sensitive clinical data to guide reperfusion decisions, prevent life-threatening complications, and establish a rehabilitation trajectory—prioritizing rapid neurological assessment, imaging interpretation, and functional status over exhaustive historical detail.

Patient Demographics & Time Documentation

• Record exact time of symptom onset (or last known well time) prominently at the top of the sheet, as this determines eligibility for thrombolysis (≤4.5 hours) and thrombectomy (≤6–24 hours) 1
• Document time of ED arrival and door-to-imaging time (target <25 minutes) to track quality metrics 1
• Include age, sex, handedness, and pre-stroke functional status (modified Rankin Scale score) 2

Chief Complaint

• Document as: "Acute onset of [right/left]-sided weakness and [associated symptoms]" with precise time of onset 1
• Note whether onset was witnessed, occurred during sleep (use last known well time), or has stuttering/progressive course 1

History of Present Illness

Stroke Characterization

• Focal neurological deficits: Specify which limbs are affected (arm > leg, leg > arm, or equal), facial droop, speech disturbance (dysarthria vs. aphasia), visual field defects, gaze deviation, sensory loss 2, 1
• NIHSS score at presentation: Document the complete 11-item scale score (0–42 range; <5 = minor stroke, >20 = major stroke) including level of consciousness, gaze, visual fields, facial palsy, motor arm/leg, ataxia, sensory, language, dysarthria, and extinction/inattention 2
• Associated symptoms: Headache, nausea/vomiting, seizure activity, loss of consciousness, chest pain, palpitations 1
• Symptom progression: Stable, improving, or worsening since onset 1

Thrombolysis Eligibility Screening

• Absolute contraindications: Active internal bleeding, recent major surgery (<14 days), history of intracranial hemorrhage, uncontrolled hypertension (SBP >185 or DBP >110 mmHg despite treatment), recent stroke or head trauma (<3 months), known intracranial neoplasm or vascular malformation 1
• Relative contraindications: Rapidly improving symptoms, mild deficits (NIHSS <4), seizure at onset, recent GI/GU bleeding, recent MI (<3 months), pregnancy 1

Past Medical History

• Vascular risk factors: Hypertension, diabetes mellitus, hyperlipidemia, atrial fibrillation, prior stroke/TIA, coronary artery disease, peripheral vascular disease, smoking history 1, 3
• Bleeding risk factors: Prior intracranial hemorrhage, coagulopathy, thrombocytopenia, recent surgery or trauma 1
• Functional baseline: Pre-stroke independence in ADLs, mobility aids used, cognitive status, living situation 3, 4

Medications

• Anticoagulants/antiplatelets: Warfarin (document last dose and INR), DOACs (apixaban, rivaroxaban, dabigatran—document last dose and timing), aspirin, clopidogrel 1
• Antihypertensives: Current regimen and adherence 1
• Diabetic medications: Insulin, oral hypoglycemics (note recent glucose control) 1

Allergies

• Document all drug allergies with reaction type, particularly to contrast agents (for CTA/CTP) and alteplase 1

Family History

• Stroke, intracranial hemorrhage, early cardiovascular disease, hypercoagulable disorders 1

Social History

• Smoking: Current, former (pack-years), never 1
• Alcohol/substance use: Quantity, frequency, recent cocaine or amphetamine use 1
• Occupation and support system: Living situation, caregivers available, baseline functional independence 3, 4

Review of Systems

• Neurological: Headache, seizures, visual changes, vertigo, prior TIA symptoms 1
• Cardiovascular: Chest pain, palpitations, orthopnea, peripheral edema 1
• Respiratory: Dyspnea, cough, aspiration symptoms 3
• Gastrointestinal: Dysphagia, recent GI bleeding, bowel habits 3
• Genitourinary: Urinary retention, incontinence, recent GU bleeding 3, 4

Physical Examination

Vital Signs & General Assessment

• Blood pressure: Both arms (document higher reading); target <185/110 mmHg for thrombolysis candidates 1
• Heart rate and rhythm: Assess for atrial fibrillation 1
• Respiratory rate and oxygen saturation: Administer O₂ if SpO₂ <92% 1
• Temperature: Fever may indicate infection or hemorrhagic transformation 1
• General appearance: Level of alertness, distress, hydration status 1

Neurological Examination (NIHSS Components)

• Level of consciousness (1a–1c): Alertness (0–3), orientation to age/month (0–2), follows commands (0–2) 2
• Cranial nerves:
  • Best gaze (CN III, IV, VI): Horizontal eye movements, forced deviation (0–2) 2
  • Visual fields (CN II): Confrontation testing, hemianopia, extinction (0–3) 2
  • Facial palsy (CN VII): Symmetry of smile/grimace, nasolabial fold flattening (0–3) 2
• Motor examination:
  • Arm drift test: Arms outstretched 90° (sitting) or 45° (supine) for 10 seconds; score each arm separately (0 = no drift, 1 = drift, 2 = some antigravity effort, 3 = no antigravity, 4 = no movement) 2
  • Leg drift test: Raise leg to 30° and hold for 5 seconds; score each leg separately (0–4 scale as above) 2
  • Tone: Spasticity, rigidity, or flaccidity in affected limbs 2, 3
• Sensory: Pinprick or light touch testing; document unilateral loss, extinction to double simultaneous stimulation (0–2) 2
• Coordination: Finger-to-nose, heel-to-shin for limb ataxia (0–2, only if out of proportion to weakness) 2
• Language: Naming objects, describing picture, reading sentences; assess for aphasia (0 = normal, 1 = mild-moderate, 2 = severe, 3 = mute/global) 2
• Dysarthria: Read list of words; assess articulation (0 = normal, 1 = mild-moderate slurring, 2 = severe/unintelligible) 2
• Neglect/extinction: Simultaneous bilateral stimulation (visual, tactile); assess for inattention (0–2) 2

Cardiovascular Examination

• Auscultation: Carotid bruits, cardiac murmurs, irregular rhythm 1
• Peripheral pulses: Symmetry, strength 1

Respiratory Examination

• Auscultation: Crackles, wheezes, decreased breath sounds 1
• Work of breathing: Use of accessory muscles, respiratory distress 1

Musculoskeletal Examination

• Shoulder assessment: Subluxation, range of motion, pain with passive movement (critical for hemiplegic shoulder pain prevention) 2, 3
• Joint positioning: Document contractures or abnormal positioning 3, 4

Skin Examination

• Pressure points: Sacrum, heels, greater trochanter, lateral malleolus—assess for early breakdown using Braden scale 3, 4

Investigations

Immediate Laboratory Tests (Do Not Delay Imaging)

• Complete blood count: Hemoglobin, platelets (thrombocytopenia <100,000 is thrombolysis contraindication) 1
• Coagulation profile: INR (must be <1.7 for tPA), aPTT 1
• Metabolic panel: Electrolytes, creatinine/eGFR (for contrast safety), glucose (hypoglycemia can mimic stroke; hyperglycemia worsens outcomes) 1
• Troponin: Assess for concurrent acute coronary syndrome 1
• Hemoglobin A1c: Long-term glucose control 1

Neuroimaging (Time-Critical)

• Non-contrast head CT: Performed within 25 minutes of arrival; interpreted within 45 minutes by experienced neuro-radiologist 1
  • Rule out hemorrhage (absolute thrombolysis contraindication) 1
  • Assess for early ischemic changes: hypodensity >1/3 MCA territory (relative contraindication to tPA due to hemorrhage risk) 1
  • Document location and extent of infarct 1
• CT angiography (CTA): From aortic arch to vertex for patients presenting ≤6 hours to identify large-vessel occlusions amenable to thrombectomy 1
• CT perfusion (optional): May identify salvageable penumbra in extended time windows (6–24 hours) 1
• MRI with diffusion-weighted imaging: Alternative to CT; more sensitive for early ischemia and posterior circulation strokes 1
• Repeat head CT at 24 hours post-thrombolysis: Screen for hemorrhagic transformation before initiating antiplatelet therapy 1

Cardiac Evaluation

• 12-lead ECG: Perform after thrombolysis decision if hemodynamically stable; assess for atrial fibrillation, acute MI, LVH 1
• Continuous cardiac monitoring: 24–72 hours to detect paroxysmal atrial fibrillation 1
• Echocardiography (transthoracic or transesophageal): For suspected cardioembolic source (young patient, no vascular risk factors, multiple vascular territories) 1

Swallowing Assessment

• Bedside swallow screen: Before any oral intake; if failed, proceed to videofluoroscopic modified barium swallow 3
• Document dysphagia: Present in up to 78% of acute stroke patients; 50% of aspirations are silent 3

Vascular Imaging

• Carotid Doppler ultrasound: Assess for significant stenosis (>70%) in anterior circulation strokes 1
• Transcranial Doppler: Monitor for vasospasm, assess collateral flow 1

Assessment

Primary Diagnosis

• Acute ischemic stroke with [right/left] hemiplegia secondary to [specify vascular territory: MCA, ACA, PCA, vertebrobasilar] occlusion/infarction 1, 5
• NIHSS score: [Document total and breakdown] 2
• Stroke severity: Minor (<5), moderate (5–15), moderate-to-severe (16–20), or severe (>20) 2

Stroke Mechanism (TOAST Classification)

• Large-artery atherosclerosis, cardioembolism, small-vessel occlusion (lacunar), stroke of other determined etiology, or stroke of undetermined etiology 1

Functional Status

• Modified Rankin Scale (mRS): Pre-stroke and current (0 = no symptoms, 5 = severe disability, 6 = death) 2
• Barthel Index: Document baseline and current scores for feeding, bathing, grooming, dressing, bowel/bladder control, toilet use, transfers, mobility, stairs (0–100 scale) 2

Complications Present or At Risk

• Immediate: Hemorrhagic transformation, cerebral edema (peaks 3–5 days), seizures, aspiration pneumonia 1, 3
• Subacute: Hemiplegic shoulder pain, DVT/PE, pressure ulcers, urinary retention/incontinence, constipation, malnutrition, depression 2, 3, 4

Management Plan

Acute Reperfusion Therapy (Time-Dependent)

• IV alteplase 0.9 mg/kg (max 90 mg): If presenting ≤4.5 hours, no contraindications, BP controlled to <185/110 mmHg; give 10% as bolus, remainder over 60 minutes 1
• Mechanical thrombectomy: If large-vessel occlusion on CTA and presenting ≤6 hours (or up to 24 hours with favorable imaging) 1
• Blood pressure management:
  • Pre-thrombolysis: Lower to <185/110 mmHg using labetalol IV, nicardipine infusion, or nitropaste 1
  • No thrombolysis planned: Treat only if SBP >220 or DBP >120 mmHg (permissive hypertension to maintain cerebral perfusion) 1

Monitoring Protocol

• Post-tPA neurological checks: Every 15 minutes × 2 hours, then every 30 minutes × 6 hours, then hourly × 16 hours 1
• Non-thrombolysis patients: Hourly neuro checks in ICU or every 4 hours on stroke unit 1
• Vital signs: Continuous cardiac monitoring, BP every 15 minutes × 2 hours post-tPA, then hourly 1

Airway & Respiratory Management

• NPO status: Until formal swallowing assessment completed 1, 3
• Supplemental oxygen: Maintain SpO₂ >92% 1
• Head positioning: Flat (0°) if no aspiration risk to maximize cerebral perfusion; elevate to 25–30° if aspiration risk, increased ICP, or respiratory compromise 1

Complication Prevention

Venous Thromboembolism Prophylaxis

• Early mobilization: Begin within 24 hours as primary prevention strategy 3, 4
• Intermittent pneumatic compression (IPC) devices: Apply within 24 hours, maintain until consistently ambulatory 3, 4
• Pharmacological prophylaxis: Consider enoxaparin 40 mg SC daily or unfractionated heparin 5000 units SC BID after hemorrhagic transformation ruled out at 24 hours 4

Pressure Ulcer Prevention

• Reposition every 2 hours: Inspect bony prominences (sacrum, heels, greater trochanter, lateral malleolus) with each turn 3, 4
• Braden scale assessment: On admission and daily; use pressure-redistributing mattress if high risk 3, 4
• Heel elevation: Off bed surface using pillows or heel protectors 4

Hemiplegic Shoulder Care

• Positioning: Affected shoulder in maximal external rotation for 30 minutes daily 2, 3, 4
• Supportive devices: Consider sling for subluxation, but avoid prolonged immobilization 2
• Range of motion: Passive ROM within pain-free range; avoid overhead pulley exercises (Class III recommendation—not recommended) 2
• Patient/family education: Proper transfer techniques—never pull on affected arm 2, 3, 4

Bladder & Bowel Management

• Remove Foley catheter within 48 hours: Initiate scheduled toileting every 2 hours during day, every 4 hours at night 3, 4
• Bowel regimen: Stool softeners, adequate hydration (1500–2000 mL/day unless contraindicated), high-fiber diet when oral intake resumed 3, 4

Nutrition

• Enteral feeding: Nasogastric or nasoduodenal tube if dysphagia present; monitor for malnutrition (affects 50% by 2–3 weeks) 1, 3, 4
• Dietitian consultation: If oral intake <50% for 3 consecutive days 4

Seizure Management

• Do NOT use prophylactic anticonvulsants: Associated with worse outcomes and impaired neural recovery 1
• Treat only recurrent seizures: Use standard anticonvulsant protocols (levetiracetam, phenytoin) 1

Cerebral Edema Management (If Develops)

• Osmotic therapy: Mannitol 0.25–0.50 g/kg IV every 6 hours if signs of increased ICP (evidence limited) 1
• Decompressive hemicraniectomy: Within 48 hours for malignant MCA infarction to reduce mortality (survivors often have severe deficits) 1

Secondary Prevention

• Antiplatelet therapy: Aspirin 160–300 mg daily initiated within 48 hours (after hemorrhage excluded at 24 hours post-tPA) 1
• Statin therapy: High-intensity statin (atorvastatin 80 mg or rosuvastatin 20 mg) regardless of baseline LDL 1
• Anticoagulation: For atrial fibrillation (initiate after hemorrhage risk assessed, typically 4–14 days post-stroke depending on size) 1
• Blood pressure control: Target <140/90 mmHg after acute phase (typically after 24 hours) 1
• Diabetes management: Target HbA1c <7%, avoid hypoglycemia 1

Rehabilitation

Early Mobilization

• Begin within 24 hours: Short, frequent sessions as soon as medically stable 1, 3, 4
• Physical therapy: Passive and active-assisted ROM, progressive mobility (bed mobility → sitting balance → standing → ambulation) 3, 4, 6
• Occupational therapy: ADL training, upper extremity function, adaptive equipment 3, 6
• Speech-language pathology: Dysphagia management, aphasia therapy 3

Psychosocial Support

• Depression screening: Within first week using validated tool (PHQ-9); affects up to one-third of patients 3, 4
• Cognitive assessment: Screen for delirium (4AT or CAM-ICU), provide orientation aids, encourage family presence 3
• Fatigue management: Affects at least 50% of survivors; schedule rest periods between therapy sessions 3

Disposition Planning

• Stroke unit admission: All patients should be admitted to dedicated stroke unit within 24 hours (reduces mortality OR 0.76, death/institutionalization OR 0.76, death/dependency OR 0.80) 1
• Discharge planning: Do NOT discharge from ED until diagnostic evaluation complete, functional status assessed, secondary prevention initiated, and clear follow-up plan established 1

Follow-Up & Documentation

Serial Assessments

• Daily NIHSS: Track neurological improvement or deterioration 2, 1
• Daily Barthel Index or mRS: Monitor functional recovery 2
• Weekly multidisciplinary team meetings: Coordinate care among neurology, nursing, PT, OT, SLP, social work 3

Discharge Documentation

• Stroke etiology workup completion: Vascular imaging, cardiac evaluation, hypercoagulable workup if indicated 1
• Rehabilitation needs: Inpatient rehab vs. skilled nursing facility vs. home with outpatient therapy 3, 4
• Secondary prevention plan: Medications, risk factor modification targets, follow-up appointments 1
• Caregiver education: Positioning, transfers, aspiration precautions, medication administration, signs of recurrent stroke 2, 3

Critical Pitfalls to Avoid

• Never delay imaging or thrombolysis while awaiting laboratory results unless specific clinical indication (e.g., suspected coagulopathy on anticoagulation) 1
• Never administer tPA if frank hypodensity involves >1/3 MCA territory on initial CT (high hemorrhage risk) 1
• Never use overhead pulley exercises for hemiplegic shoulder (increases pain and subluxation risk) 2
• Never initiate oral intake before swallowing assessment (aspiration pneumonia increases mortality 7-fold) 3
• Never use prophylactic anticonvulsants in acute stroke (impairs neural recovery) 1