Mrs. Lee's Care Plan

1. Assessment

1.1. Subjective

1.1.1. Decreased the left side of partial vision

1.1.2. Paralysis and sensory deficit of the left side of arm and leg

1.2. Objective

1.2.1. Blood glucose assessment with H’stix 4.5 mmol/L

1.2.2. Difficulty in swallowing food

1.2.3. Aphasia

1.2.3.1. Not able to properly understand or express language

2. Current history

2.1. History of present illness

2.1.1. Mild confusion at 4 pm

2.1.2. Slurred speech

2.1.3. Left side of the face drooping

3. Diagnostics

3.1. Labs

3.2. Radiology

3.2.1. CT scan

3.2.1.1. A thrombus in a branch of the right internal carotid artery

3.2.1.1.1. Right side ischaemic stroke

4. Patient‘s data set

4.1. 60-year-old

4.2. Female

4.3. Married

4.3.1. Living with her daughter

5. Past medical history

5.1. Had been treated for atrial fibrillation for 10 years

5.2. Often not compliance with her medications

6. Medication list

6.1. thrombolytic therapy with IV recombinant t-PA