Resident guide

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Stroke Code and Ischemic Strokes

  1. Obtain basic quick history(1-2 min)
    • Time of symptom onset
    • Last Known Well
    • PMH HTN?, Afib?, Dyslipidemia?, CAD?, other relevant to stroke
    • Meds (antiplatelets, anticoagulation)
  2. Examine patient using NIHSS
  3. CT head (c-) is a PRIORITY!! ASAP
    • Obtain CT Head and Neck ANGIOGRAM if patient is in window for intervention, unless significant contraindication. CT head is to rule out ICH or large space occupying lesion. CT angio is to identify if patient has thrombus which can be accessed via DSA.
  4. Obtain preliminary read from radiology. Obtain ASPECTS score if indicated.
    • ASPECT score is warranted in MCA ischemic strokes that are possible endovascular candidates.
  5. Present to Attending for plan.


  • Assess if patient is IVtPA candidate
    • Patient should be symptomatic and present within 4.5hr of last seen at baseline.
      • 3-4.5hr window patient must meet following criteria:
        • Age <80
        • Patient does not have history of BOTH stroke AND diabetes
        • Patient is not taking ANY anticoagulant
        • NIHSS < 25
        • Informed consent obtained
      • Patient should meet inclusion and exclusion criteria.
  • Complete stroke thrombolytic order sheet and fax to pharmacy (Fax: 4849; Phone: 7207)
    • IV TPA dosing: TOTAL DOSE: 0.9mg/kg
      • INITIAL BOLUS: 10% of total dose
      • REMAINING DOSE: 90% of total dose
  • Prior to administering IV TPA:
    • Obtain IV access
    • Obtain T&S
    • Place foley
    • Ensure BP < 185/90
      • If needed give labetalol push or place on Cardene drip
  • Administer INITIAL BOLUS over 1 minute. REMAINING DOSE to be administered IVPB over 1 hour.
  • After administration of IV TPA, monitor patient closely:
    • Vital signs and NIHSS q15min x 2hr then q30min x6hr then q1hr.
  • If worsening NIHSS obtain STAT CT head otherwise repeat CT head within 24hr s/p IVTPA.


  • Stop Alteplase Infusion
  • Labs:
    • CBC, PT(INR), aPTT, fibrinogen level, and type and cross match
  • Cryoprecipitate (includes factor VIII)
    • 10 Units infused over 10-30 minutes (Onset is 1 hr, peak at 12 hr)
    • Administer additional dose for fibrinogen level of <200 mg/dL
  • Tranexamic acid 1000mg IV infused over 10 minutes OR aminocaproic acid 4-5g over 1 hr, followed by 1 g IV until bleeding is controlled (peak onset in 3hrs)
  • Supportive therapy including BP management, ICP, CPP, MAP, temperature, and glucose control


  • Assess if patient is an endovascular candidate
    • ASPECT Score >6
    • NIHSS >6
    • Presenting within 6hr of last seen baseline
      • Note Anterior circulation strokes should present within 6hr and Posterior circulation stroke can present within 8-24hr depending on case. ASPECTS only applies to MCA stroke.
  • Inform Endovascular Attending on call and notify anesthesia P: 0838/0836
  • Obtain CTA head and neck to assess for proximal vessel occlusion.
  • If CTA reveals proximal vessel occlusion inform Endovascular Attending and bring patient to VIR suite.
  • Endovascular interventional cases are admitted under NES for first 24hr.
Inclusion Exclusion
-Age 18 years or older.

-Clinical diagnosis of ischemic stroke.

-(NIHSS) greater than 3 and less than 22.

-CT must exclude hemorrhagic stroke or advanced evidence of infarction.

-Time of symptom onset well established to be less than 180 minutes.


-History of ICH -History of intracranial neoplasm/Arteriovenous Malformation (AVM)/aneurysm/ICH

-High clinical suspicion of SAH even with normal CT scan.

-Active internal bleeding (e.g. gastrointestinal bleeding or urinary bleeding within the last 21 days) or acute trauma (fracture) on examination.

-Lumbar puncture or arterial puncture at non-compressible site in previous 7 days

-Known bleeding diathesis, including but not limited to:

-Platelet count < 100,000

-Patient has received heparin within 48 hours and elevated aPTT.

-Use of anticoagulant with INR greater than 1.7

-Head trauma or prior stroke in previous 3 months

-Major surgery or serious trauma in previous 14 days

-MI in previous 3 months

-Clinical presentation of a seizure with postictal residual neurological impairments, unless the CTA shows major arterial branch occlusion.

-Positive pregnancy test.Glucose <,50 mg/dL or >,400 mg/dL

-Serious or chronic medical illness that may interfere with the benefits from Alteplase


-Minor (Less than 4 points on NIH Stroke Scale) or rapidly improving symptoms

-SBP greater than 185 mmHg or DBP greater than 110 mmHg at time of treatment

-Aggressive therapy (drips) needed to keep pressure in specific limits


-Evidence of intracranial hemorrhage on noncontrast CT scan

-Non-ischemic intraaxial pathology- abscess, tumor

-CT shows a multilobar infarction involving > 1/3 of the MCA territory.

Hemorrhagic Stroke

NES consult STAT

  • Vitals: BP <140/90
  • Medications:
    • Platelet/FFP/PCC/Vitamin K for reversal if indicated
    • Labetalol 10mg IV push PRN for SBP >150,
    • Keppra for seizure prophylaxis if indicated
    • IV hydration while NPO
    • No Anticoagulation or antiplatelets
    • DVT prophylaxis
  • Diet: NPO
  • Activity: HOB at 30 degrees, Bed rest
  • Hemorrhagic Stroke work up: MRI brain C+/C- and MRA head and neck (if CTA not already done)
  • Rehab Therapies: PT/OT/ST and swallow evaluation

TIA and ABCD2 Score

ABCD2 Score Calculator

ICH Score

Click for online calculator: Glasglow Coma Scale (GCS)
Glasgow Coma Scale
Eye Opening Verbal Response Motor Response
4 = opens spontaneously

3= opens to voice 2= opens to pain 1= none

5= normal conversation (AAOx3)

4= disoriented conversation 3= words, incoherent 2=incomprehensible sounds 1=none

6= normal

5=localizes to pain 4=withdraws from pain 3=decorticate posturing (flexion) 2=decerebrate posturing (extension) 1=none

Total Score:

Best Response: 15
Comatose Patient: 8 or less
Totally unresponsive: 3

Click for online calculator: ICH SCORE
3-4 2 pts
5-12 1 pt
13-15 0 pts
ICH Volume
<30 0 pts 0 None
IVH 1 13%
Yes 1 pt 2 26%
No 0 pts 3 72%
Location 4 97%
Infratentorial 1 pts 5 100%
Supratentorial 0 pts 6 100%
≥ 80 1 pt
<80 0 pts

Subarachnoid Hemorrhage (SAH)


  • Trauma
  • Aneurysm (saccular)
  • AVM
  • ICH with extravasation
  • Venous occlusion


  • CT scan is 90-95% sensitive within 24 hours, and decreases to ~ 80% at 72 hours.
  • If CT is negative, but history is concerning, do an LP.
    • LP results (rule of ½):
      • RBCs appear at ½ hour
      • Xanthochromia appears at ½ day
      • RBCs disappear at ½ week
      • Xanthochromia disappears at ½ month
  • If the CT or LP is positive, urgent 4-vessel cerebral angiogram to look for aneurysm, possible clipping or coiling.
  • MRA usually detects aneurysm of 4mm or greater size.


  • Rebleeding can usually occur within first 24 hours
  • DCI (delayed cerebral ischemia)
  • Hydrocephalus
  • Seizures
  • Vasospasm is usually delayed by about 5 days, but highest risk ~ day 4-11
  • Hyponatremia from SIADH or cerebral salt wasting. Note that cerebral salt wasting looks just like SIADH based on serum and urine lytes, so be sure you know how to tell the difference as the treatment is vastly different.

For cerebral salt wasting:

  • check urine osms (normal is 285)
  • 0.9% NS has osm of 308, 1.8% with 616, 3% with >900
  • If urine osms >308, then NS is not enough, consider 1.8% or 3%
  • Do not run 3% through a peripheral line

Other systemic complications:

  • Pulmonary edema
  • Arrhythmia


  • Bed rest with HOB >30 degrees
  • Blood pressure management to keep MAP around 120.
  • Nimodipine 60mg po q4h for 21 days to reduce the risk of vasospasm.
It should be noted that this agent has been shown to improve neurological outcomes but not cerebral vasospasm. The value of other calcium antagonists, whether administered orally or intravenously, remains uncertain
  • Pain management
  • Transcranial Doppler (TCD) to monitor for development of vasospasm

For Delayed Cerebral Ischemia (DCI)

DCI, especially that associated with arterial vasospasm, remains a major cause of death and disability in patients with aSAH
  • Treatment:
    • Triple H therapy may be considered for vasospasm and use 0.9% Normal Saline
      • Hypervolemia
      • Hemodilution
      • Hypertension (unless blood pressure is elevated at baseline or cardiac status precludes it)

Managing Seizures in SAH

  • Prophylactic anticonvulsants may be considered in the immediate posthemorrhagic period
  • Routine long-term use of anticonvulsants is not recommended. Consider it in patients with known risk factors for delayed seizure disorder:
    • History of prior seizure
    • Intracerebral hematoma
    • Intractable hypertension
    • Infarction
    • Aneurysm at the middle cerebral artery

Reversal of Anticoagulation

-Vitamin K 5mg-10mg IV (over 10 minutes) + PCC
-Pretreatment INR: 2 to <4: Administer 25 units/kg; maximum dose: 2,500 units
-Pretreatment INR: 4 to 6: Administer 35 units/kg; maximum dose: 3,500 units
-Pretreatment INR: >6: Administer 50 units/kg; maximum dose: 5,000 units
Protamine sulfate: 1 mg for every 100 u of heparin administered in the previous 2 -3 hr; administer by slow IV injection over 10 min; maximum single dose: 50 mg.
plaPelet transfusion (1u if on ASA 81-325; 2u if on Clopidigrel OR dual antiplatelet), DDVAP
If symptomatic ICH after TPA within the last 24hrs: 6 units of FFP and 10 units cryoprecipitate (Check fibrinogen level 1hr after administration of Cryo, goal Fibrinogen >150 mg/dL, 10 u of Cryo raise levels by 70mg/dL)
<5 None or Minimal Hold warfarin for 1-2 days or decrease dose.
5-9 None or Minimal Hold warfarin and resume when INR is therapeutic; administer low dose (1-2.5 mg) oral vitamin K if there is increased risk of bleeding.
>9 None or Minimal Hold warfarin and administer high dose (2.5-5mg) oral vitamin K.
Any Serious or life threatening Hold warfarin and administer intravenous vitamin K 10mg, FFP, recombinant factor VIIa, or prothrombin complex concentrate.


  • Protein S
  • Protein C
  • Anti-thrombin III
  • Anticardiolipin Ab
  • Lupus anticoagulant
  • Beta 2 glycan
  • Homocysteine
  • Factor VIII (misc slip-blue top)
  • Factor V Leiden Mutation (needs consent)
  • Prothrombin Mutation (needs consent)

Increased Intracranial Pressure (ICP)

Key Formulas

  • CPP = MAP - ICP
  • MAP = ((2 x diastolic) + systolic)/3

CPP = Cerebral perfusion pressure, MAP = Mean arterial pressure, ICP = Intracranial pressure

Normal Values

  • Normal ICP is 5-15 cm H20.
  • Normal CPP is > 60 cm H2O

Herniation Syndromes

  • Cingulate herniation: Displacement of the cingulate gyrus under the falx cerebri with subsequent compression of the internal cerebral vein. Can compress the ipsilateral anterior cerebral artery producing subsequent vascular ischemia, edema, and progressive mass effect.
  • Central / transtentorial herniation: Downward displacement of the hemisphere with compression of the diencephalon and midbrain through the tentorium. Displacement of the diencephalon against the midbrain produces hemorrhage in the pretectal region and the thalamus. The medial perforating braches of the basilar artery rupture during derniation of the midbrain and pons.
  • Uncal herniation: Shift of the temporal lobe, uncus, and hippocampal gyrus toward the midline with compression of the adjacement midbrain. *Ipsilateral third cranial nerve and PCA compressed by uncus and edge of the tentorium. Leads to a dilated ipsilateral pupil and occipital lobe ischemia. Further increased ICP from compression of the aqueduct. Expansion of the supratentorial volume can produce pressure necrosis of the para-hippocampal gyrus.
  • Cerebellar tonsillar herniation: Compression of the medulla with respiratory compromise and death.
  • Upward cerebellar herniation: Causes hydrocephalus, coma. Caudal to rostral progression of dysfunction.

Treatment of increased ICP

  • Head of bed at >= 30 degrees.
  • Decrease stimulation.
  • No hypotonic fluids. If you need to treat hypernatremia, use enteral free water.
  • Hyperventilation to pCO2 of 25-30 has an immediate effect, but is short lived. Hypocapnia causes cerebral vasoconstriction.
  • Mannitol: 0.5 - 1 g/kg IV load over 10 minutes followed by 0.25 - 0.5 g/kg IV q4-6 hours. Check serum osmolality and aim for a goal of 310-320. Don't use longer than 5 days.
  • Steroids: Only useful for vasogenic edema (i.e. tumors, abscesses). Dexamethasone 4 mg or methylprednisolone 20mg. The is no indication for steroids for edema due to ischemic or hemorrhagic stroke.
  • Consult neurosurgery for consideration of ventriculostomy or decompression.
  • Consider pharmacological coma or hypothermia.



  • ANA
  • Rheumatoid Factor
  • RPR or VDRL
  • Hepatitis B Core Ab
  • Hepatitis B Core IgM Ab
  • Hepatitis B Surface Ab
  • Hepatitis B Surface Ag
  • Hepatitis C Ab
  • ESR
  • Cryoglobulins
  • HSV AB 1/2 IGG IGM w/ RFX
  • HIV
  • C-reactive Protein
  • ACE level
  • C1Q binding protein
  • SSA and SSB (Sjogren’s Ab), pANCA
  • cANCA
  • C3/C4 Levels
  • SPEP
  • Anti-Ds DNA Ab
  • Lyme
  • Homocysteine
  • Lupus anticoagulant

Carotid Stenosis

Status Epilepticus

  1. Diagnose, O2, ABCs, obtain IV access, draw blood for Chem-7, Mg, Ca, CBC, LFTs, AED levels, ABG, toxicology screen (urine & blood)
  2. Thiamine 100mg IV, 50 mL of D50 IV unless adequate glucose known
  3. Lorazepam 2mg IV to a max of 8mg over 8-10min. Alternatives: Diazepam 20mg PR or Midazolam 10mg IM
  4. Fosphenytoin 20mg/kg IV at 150 mg/min with BP and EKG monitoring
  5. If seizure persist, give one of the following (Intubation necessary except for valproate)
  • IV Midazolam:
    • LOAD: 0.2 mg/kg; repeat 0.2-0.4mg/kg boluses every 3-5 min until seizures stop up to max total loading dose 2mg/kg.
    • INITIAL IV RATE: 0.1mg/kg/hr (Range 0.05-2.9 mg/kg/hr)
  • IV Propofol:
    • LOAD: 1-2mg/kg; repeat 1-2 mg/kg boluses every 3-5 min until seizures stop to max loading dose 10mg/kg.
    • INITIAL RATE: 2mg/kg/hr (Range 1-15mg/kg/hr)
      • Avoid >5mh/kr/hr for multiple days to minimize risk of propofol infusion syndrome.
  • IV Phenobarbital: 20mg/kg at 50-100mg/min
  • IV Valproate: 30-40mg/kg at 20 mg/min
  • IV Pentobarbital:
    • LOAD: 5mg/kg up to 50mg/min. Repeat 5mg/kg boluses until seizures stop to max 20mg/kg.
    • DOSE RANGE: 1-10 mg/kg/hr
  • Thiopental
    • LOAD: 5-10mg/kg bolus
    • RATE: 4-6mg/kg/hr


  • Long term video EEG
  • Labs: CK, Urine drug screen
  • Nursing Orders:
    • Sleep deprivation until 2am
    • Photic stimulation
    • Hyperventilation
  • Medications:
    • Anti-epileptic Drugs as per Attending
    • Ativan PRN for seizure
  • Precautions: seizure, fall, aspiration


  • CBC, BMP
  • Collagen Vascular Disease work up (ANA, Anti-dsDNA, RF, anti- ro, anti- la, ESR, CRP, Complement C3, C4)
  • HbA1c, Thyroid Function Tests
  • Cryoglobulinemia
  • SPEP
  • CSF-Cell count, IgG, ACE, Cytology
  • Paraneoplastic work up
  • Vitamin B6, Vitamin B12, Folate, Homocysteine, Methylmalonic Acid
  • Copper, Zinc
  • Toxic Drugs: Vincristine, Paclitaxel, Cisplatinum, Vinca alkaloids, Pyridoxine, Lithium, INH, Disulfiram, Hydralazine, Acrylamide, Alcohol, Arsenic, Lead, Mercury, Thallium, Cyanide, Organophosphates, Amiodarone, Metronidazole, Phenytoin, Zalcitabine, Didanosine, Dapsone
  • EMG
  • Genetic testing if indicated (i.e. Charcot Marie Tooth)


  • CBC, BMP
  • CPK
  • ESR, CRP
  • TFT
  • Collagen Vascular Disease w/I if indicated
  • Paraneoplastic Disorders w/u if indicated
  • Skin, Nerve, Vessel Biopsy
  • EMG
  • Genetic Testing

Myasthenia Gravis

  • TFTs
  • anti-acetylcholine receptor (AChR)
  • anti-muscle-specific tyrosine kinase (MuSK) antibodies
  • Tensilon Test (not frequently used)
  • CT Chest
  • EMG
  • Monitor NIF and FVC if <20cmH2O and <1cm respectively, intubate
  • Plasmapheresis or IVIG 0.4g/kg/day for 5 days.
Medication Contraindicated in MG
  • Antibiotics
    • Aminoglycosides, Ampicillin, Ciprofloxacin, Macrolides, Imipenem
  • Cardiologic
    • B-blockers, Ca channel blockers, Antiarrhythmic agents (procainamide, quinine, quinidine)
  • AED
    • Phenytoin, Carbamazepine
  • Ophthalmologic
    • Timolol
  • Psychiatric
    • Lithium, Benzodiazepines
  • GI
    • Mg salt, Antacids
  • Others
    • Chloroquine, Penicillamine, Interferons

Multiple Sclerosis

Initial Workup
  • MRI brain and Neuro-axis c+/c-
  • Visual evoked potential
  • Labs
Myelin Basic Protein A2K Misc Slip
Oligoclonal Bands A2K Misc Slip
IgG index A2K A2K
CSF Cell Count and Diff A2K ---
ACE Level Misc Slip A2K
NMO/AQP-4 ab Misc Slip Misc Slip
Anti MOG ab Misc Slip Misc Slip

  • Methylprednisone IVPB 250mg q6hrs for 12-15 doses
  • GI prophylaxis with protonix while on steroids
  • Lispro sliding scale while on steroids
  • Discharge on PO steroid taper and protonix


Meningitis Type Glucose




Bacterial Low High PMNs >300
Viral Normal Normal

or High



TB Low High Mononuclear and PMN


Fungal Low High <300
Malignant Low High Usually Mononuclear


  • Drug history (i.e. analgesics, sedatives, anti-cholinergic agents)
  • MMSE or MoCA
  • Basic labs: CBC, BMP
  • Thyroid Function tests
  • Vitamin B12
  • Methylmalonic Acid and Homocysteine
  • Vitamin B1 (Thiamine)
  • Heavy metal screen
  • Paraneoplastic
  • Genetic testing for DLB
  • CT head or MRI brain
  • EEG
  • Lumbar puncture (CSF)
    • TAU/AB42
    • Protein 14-3-3
    • APOE genotyping
    • Lyme Titer
    • VDRL
    • Paraneoplastic Panel
  • Neuropsychological testing

Praneoplastic Syndromes

Initial Testing
  • ANN1S: Anti-Neuronal Nuclear Ab, Type 1
  • ANN2S: Anti-Neuronal Nuclear Ab, Type 2
  • ANN3S: Anti-Neuronal Nuclear Ab, Type 3
  • AGN1S: Anti-Glial Nuclear Ab, Type 1
  • PCABP: Purkinje Cell Cytoplasmic Ab Type 1
  • PCAB2: Purkinje Cell Cytoplasmic Ab Type 2
  • PCATR: Purkinje Cell Cytoplasmic Ab Type Tr
  • AMPHS: Amphiphysin Ab, S
  • CRMS: CRMP-5-IgG, S
  • STR: Striational (Striated Muscle) Ab, S
  • CCPQ: P/Q-Type Calcium Channel Ab
  • CCN: N-Type Calcium Channel Ab
  • ARBI: ACh Receptor (Muscle) Binding Ab
  • GANG: AChR Ganglionic Neuronal Ab, S
  • VGKC: Neuronal (V-G) K+ Channel Ab, S
Reflex Testing
  • GD65S: GAD65 Ab Assay, S
  • WBN: Paraneoplastic Autoantibody WBlot,S
  • ARMO: ACh Receptor (Muscle) Modulating Ab
  • ABLOT: Amphiphysin Western Blot, S
  • NMDIS: NMDA-R Ab IF Titer Assay, S
  • AMPIS: AMPA-R Ab IF Titer Assay, S
  • GABIS: GABA-B-R Ab IF Titer Assay, S
  • CRMWS: CRMP-5-IgG Western Blot, S
  • LG1CS: LGI1-IgG CBA, S

Guillain-Barre Syndrome

  • LP for CSF
    • Albuminocytologic dissociation: elevated protein with normal wbc
    • Demyelinating forms: decreased motor nerve conduction velocity, prolonged distal motor latency, increased F wave latency, conduction blocks, and temporal dispersion.
    • Axonal forms: decreased distal motor and/or sensory amplitudes.
  • Anti-GQ1b antibody if indicated
    • Present in 90% cases of Miller-Fisher variant (triad: ophthalmoplegia, ataxia, arreflexia)
  • Spinal MRI if indicated
    • May reveal thickening and enhancement of the intrathecal spinal nerve roots and cauda equina
  • IVIG: 0.4g/kg for 5days
    • Check IgA level prior to IVIG administration. If absent you cannot give IVIG
  • Plasmapheresis: 40-50ml/kg for 5 doses
    • Call pediatric hematology to set up plasmapheresis.
  • NIF and FVC q4hr
    • If NIF <20cmH2O and FVC <1cm, intubate
Cardiac monitoring
DVT prophylaxis

Autoimmune Panel

  • Anti-nuclear Ab
  • Anti-ds DNA
  • Complement 3 and 4
  • SSA and SSB (Sjogren’s Ab)
  • Rheumatoid Factor
  • Thyroglobulin
  • Anti-thyroid Peroxidase
  • Parietal Cell Ab
  • Anti-mitochondrial Ab
  • C-reactive Protein
  • Sed rate
  • Vitamin D
  • Striated Muscle Ab w/rflx
  • Sm/RNP Antibodies
  • Scleroderma
  • Anti-C1q
  • Anti-GM1
  • Anti-Mag

Encephalitis Panel

Hypoxic Brain Injury

  • Long term video EEG
  • CT head C- and MRI Brain
  • SSEP (median): Somatosensory evoked potential Median Nerve
  • NSE: Neuron Specific Enolase

Brain Death

  • 2 Exams of cerebral and brain stem function 6hr apart
  • APNEA TEST (preformed at end of 2nd exam)
    1. Pre-oxygenate at 100% for 10min
    2. Reduce RR to 10 and PEEP to 5
    3. Draw baseline ABG
    4. Discontinue Vent and place O2 NC at level of carina at 6L
    5. ABG immediately and after 5min
    6. Apnea
  • No spontaneous breathing movements
  • PCO2 to 55, or increase PC02 by 20, and/or pH less than or equal to 7.25


Phone Numbers


    • CONSULT 0838
    • STAT AIRWAY 0980
  • CARDIOLOGY- also can input computer consult
    • GENERAL 0637 (AFTER HOURS 952-8967) –Also on TigerText
  • DENTAL – OMFS 0381
  • ENDOCRINE 0702
    • GI 321-9407
    • LIVER 952-0049
    • (Mon-Fri) 0501
    • Weekends/Holidays- check iCare
  • OBSTETRICS/GYNECOLOGY call operator or L&D and ask to speak to Ob/Gyn resident
  • OPHTHALMOLOGY 952-1015
  • PALLIATIVE- also can input computer consult.
    • Office: x3112
  • PICC NURSES x8732
  • PSYCHIATRY 0987 – also can input computer consult
  • PULMONARY/CRITICAL CARE 952-1669. Pulmonary consult-can input in computer
    • Mon-Fri 9-5 office: x7701
    • After hours: 952-5050
  • SURGERY 0298
  • UROLOGY- check AMION