Intracerebral Hemorrhage Progress Note Template, Risk factors for ICH (e.g., hypertension, anticoagulant use, smoking).
Patient: [Patient Name] MRN: [Medical Record Number] Date: [Date of Visit]
主诉 (zhǔ訴) Chief Complaint:
Document the patient’s main presenting concerns related to intracerebral hemorrhage (ICH). This may include:
Sudden onset of headache (often described as the worst headache of their life)
Altered mental status (confusion, lethargy, coma)
Seizures (in some cases)
Weakness or paralysis on one side of the body (hemiparesis)
Speech difficulties (aphasia)
Nausea and vomiting
现病史 (xiàn bìng shǐ) History of Present Illness:
Onset and duration of symptoms.
Witnessed collapse or loss of consciousness (if applicable).
Prior neurological symptoms (if any).
Risk factors for ICH (e.g., hypertension, anticoagulant use, smoking).
既往史 (jì wàng shǐ) Past Medical History:
Hypertension (a major risk factor)
Atherosclerosis
Cerebrovascular disease (prior stroke or transient ischemic attack)
Coagulopathy (abnormal blood clotting)
Head trauma
Amyloid angiopathy (a condition affecting blood vessel walls)
Prior use of anticoagulant medications or antiplatelet medications
家族史 (jiā zú shǐ) Family History:
Family history of stroke (increased risk)
社会史 (shè huì shǐ) Social History:
Smoking history (risk factor)
Alcohol abuse (risk factor)
Illicit drug use (cocaine use can increase risk)
查体 (chá tǐ) Physical Examination:
Vital signs (often elevated blood pressure, may have fever)
General examination: assess for level of consciousness (Glasgow Coma Scale).
Neurological examination:
Focal weakness (hemiparesis)
Sensory deficits
Aphasia (difficulty with speech)
Ataxia (incoordination)
Meningismus (signs of irritation of the meninges, in some cases)
Fundoscopy (examination of the eye) may show retinal hemorrhages.
辅助检查 (fú zhu zhuān chá) Laboratory Tests:
Complete blood count (CBC) to assess for blood cell abnormalities.
Coagulation profile (INR, PTT) to assess blood clotting function.
Blood glucose level
Electrolytes
影像学检查 (yǐng xiàng xué jiǎn chá) Imaging Studies:
Non-contrast head CT scan: The initial imaging study to confirm ICH and identify location and size of the bleed.
Head MRI (may be done later) to differentiate ICH from other causes and assess for complications.
诊断 (zhěn duàn) Diagnosis:
Intracerebral hemorrhage (ICH).
Specify the location of the bleed (e.g., lobar hemorrhage, putaminal hemorrhage).
Indicate the severity of the ICH based on imaging findings and clinical presentation (e.g., ICH score).
分期 (fēn qī) Staging (optional):
Some classification systems categorize ICH severity based on clinical presentation and imaging findings (e.g., ICH score, Glasgow Coma Scale).
治疗方案 (zhì liáo fāng àn) Treatment Plan:
Treatment for ICH focuses on stabilizing the patient’s condition, preventing further bleeding, and managing complications.
This may include:
Blood pressure control (critical for preventing re-bleeding)
Airway management (if needed)
Intravenous fluids
Seizure prophylaxis (if indicated)
Surgical intervention (rarely, for large hemorrhages causing severe pressure)
Supportive care (pain management, rehabilitation)
预后 (yù hòu) Prognosis:
Discuss the outlook based on the severity of the bleed, location, and the patient’s overall health.
ICH is a serious condition with high mortality and morbidity rates.
Survivors may experience long-term neurological deficits requiring rehabilitation.
健康指导 (jiàn kāng zhǐ dào) Patient Education:
Importance of medication adherence, especially for blood pressure control.
Lifestyle modifications to reduce risk factors (smoking cessation, healthy diet).
Following rehabilitation recommendations to improve function.
Note: This is a template. The specific information documented will vary depending on the individual patient.