Discharge Summary

[Please start with this - Course in hospital - for all patients, issue-based]

THE FOLLOWING IS AN ISSUE-BASED COURSE IN HOSPITAL:

1) STROKE

PRIMARY STROKE Diagnosis:

[Cause of Stroke option 1 - Ischemic Stroke - select as applicable]

Acute Ischemic Stroke - due to Small Vessel Disease
Acute Ischemic Stroke - due to Extracranial Large Vessel Disease
Acute Ischemic Stroke - due to Aortic Arch Atheroma
Acute Ischemic Stroke - due to Atrial Fibrillation
Acute Ischemic Stroke - due to Cardioembolism (valve, structural heart disease, infective endocarditis)
Acute Ischemic Stroke - due to Intracranial Atherosclerotic  Disease (ICAD)
Acute Ischemic Stroke - due to Hypercoagulable State
Acute Ischemic Stroke - due to PFO
Acute Ischemic Stroke - due to Dissection
Acute Ischemic Stroke - due to CVST
Unknown Etiology - Acute Ischemic Stroke - due to a cause that is yet not identified;  Outpatient or in-hospital/in-facility (if transferred to another facility) on-going workup is pending

[Cause of Stroke option 2 - Hemorrhagic Stroke - select as applicable]

Acute Hemorrhagic Stroke - Primary ICH - suspected due to Hypertension
Acute Hemorrhagic Stroke - Primary ICH - suspected due to Amyloid Angiopathy
Acute Hemorrhagic Stroke - Secondary ICH - due to underlying neurovascular lesion
Acute Hemorrhagic Stroke - Secondary ICH - due to Coagulopathy

[Main Stroke Treatment - for all patients - issue-based]

Stroke Treatment:

-IV Thrombolysis [include details where possible]

-endovascular therapy (EVT) [include details where possible]

-endovascular STENT was deployed (please note these patients require 3 months of DAPT) [include details where possible]

-Standard Medical Care [Anti-platelet agents, Anticoagulation, Antihypertensives, and statin therapy]

Pertinent Imaging:

*Research study participation: [Only include if answer is yes and indicate research study]

[Medical Issues - for all patients - issue-based - If No medical issues, state None]

2) MEDICAL ISSUES (issue and plan):

- A Fib

-Acute coronary Syndrome

- CHF

- DVT/PE

-Pneumonia

[Incidental Findings - for all patients]

3) INCIDENTAL FINDINGS:

Please see the imaging section, where imaging reports are available as part of this discharge summary.

[Incidental Thyroid Nodule]

You have been found to have a thyroid nodule, this requires follow-up, we request that you please see your family physician within 2 weeks, such that this can be addressed with a referral to either head and neck surgery, or an endocrinologist for appropriate testing, or both.  It is quite important that you please follow-up on your thyroid nodule.

[Incidental Lung Nodule]

You have been found to have a lung nodule, this requires follow-up, we request that you please see your family physician within 2 weeks such that this can be addressed with a referral to either respiratory medicine, or another physician, as required for additional appropriate testing.  It is quite important that you please follow-up on your lung nodule.

4) DISPOSITION

Discharge mRS:
0 No symptoms (able to carry out all usual activities)
1 No significant disability (able to carry out all usual activities despite some symptoms)
2 Slight disability (able to look after own affairs and perform ADLs without assistance)
3 Moderate disability (requires some help with ADLs but able to walk independently – cane or walker is permitted)
4 Moderate-severe disability (unable to attend to own bodily needs without assistance; unable to walk unassisted)
5 Severe disability (requires constant nursing care, bedridden, incontinent, unable to be left alone for a few hours)

Discharge destination: [Home / Rehabilitation / Other acute care hospital / Nursing home or palliative care centre or other medical facility]

[Follow-up Plan - For all Patients]

FOR ALL OF OUR PATIENTS - We request that you see your Primary Care Provider (family doctor) for Follow-up after being in hospital:

For all of our patients, because you have recently been to hospital, we request that you please follow-up with your family physician within 1-2 weeks of discharge (either from Home, or after your discharge from Rehabilitation Facility).

If you do not have a family doctor - please call or register on the website listed here:  phone at 1-800-445-1822, Monday to Friday, 9am to 5pm. See website: https://www.ontario.ca/page/find-family-doctor-or-nurse-practitioner

Register at: https://hcc3.hcc.moh.gov.on.ca/HCCWeb/

Please call your family physician's office and book an appointment to be seen in follow-up.  If you do not have a family physician, please obtain a family physician (as above).  In the interim, please see a walk-in clinic within 1-2 weeks to ensure that you are clinically well, and can have follow-up tests at the discretion of the physician, you are seeing. You may be needing some additional testing such as blood work.  One of the key items to have follow-up after discharge, in the setting of stroke, is your blood pressure, and we recommend that you have close follow-up after discharge with regard to this issue with your Family doctor and/or walk-in clinic.

**We reviewed the symptoms and signs of TIA and Stroke, and the patient or their SDM (substitute decision maker) knows to call 911 should they experience a sudden onset of any focal neurological deficits. **

STROKE PREVENTION PLAN:

For stroke treatment and prevention, you have been started on the following agents:

[option 1 - Single Antiplatelet]

You have been started on a SINGLE antiplatelet: You have been started on Aspirin 81mg daily.  If you experience any serious bleeding please seek immediate medical attention. For additional information on Antiplatelet medications, and what to expect about the possibility of bruising or minor bleeding, please visit the Heart and Stroke website at: https://www.heartandstroke.ca/heart/treatments/medications/antiplatelet-medications 

[option 2 - MINOR STROKE or TIA - DAPT 3 Weeks then Clopidogrel]

You have been started on - DUAL antiplatelet therapy for TIA or minor stroke: You have been started on Aspirin 81mg daily and Clopidogrel (also called PLAVIX) 75mg daily - for a Total of 3 weeks. Please discontinue ASA  at the end of 3 weeks and continue to take Clopidogrel (PLAVIX)  75mg indefinitely. If you experience any serious bleeding please seek immediate medical attention. For additional information on Antiplatelet medications, and what to expect about the possibility of bruising or minor bleeding, please visit the Heart and Stroke website at: https://www.heartandstroke.ca/heart/treatments/medications/antiplatelet-medications 

[option 3 - MINOR STROKE or TIA - DAPT 3 Weeks then ASA]

You have been started on - DUAL antiplatelet therapy for TIA or minor stroke: You have been started on Aspirin 81mg daily and Clopidogrel (also called PLAVIX) 75mg daily - for a Total of 3 weeks. Please discontinue Clopidogrel (PLAVIX) at the end of 3 weeks and continue to take ASA 81mg indefinitely. If you experience any serious bleeding please seek immediate medical attention. For additional information on Antiplatelet medications, and what to expect about the possibility of bruising or minor bleeding, please visit the Heart and Stroke website at: https://www.heartandstroke.ca/heart/treatments/medications/antiplatelet-medications 

[option 4 - DAPT 3 months then Clopidogrel - Intracranial Atheroscleortic Disease/ICAD]

You have been started on - DUAL antiplatelet therapy for symptomatic, severe intracranial atherosclerosis.  Please continue to take aspirin 81 mg p.o. daily, along with Clopidogrel (also called PLAVIX) 75 mg p.o. daily, together for a total duration of 3 months.  After 3 months, continue on Clopidogrel (also called PLAVIX)  75 mg orally daily. If you experience any serious bleeding please seek immediate medical attention. For additional information on Antiplatelet medications, and what to expect about the possibility of bruising or minor bleeding, please visit the Heart and Stroke website at: https://www.heartandstroke.ca/heart/treatments/medications/antiplatelet-medications 

[option 5 - DAPT 3 months then ASA - Intracranial Atheroscleortic Disease/ICAD]

You have been started on - DUAL antiplatelet therapy for symptomatic, severe intracranial atherosclerosis.  Please continue to take aspirin 81 mg p.o. daily, along with Clopidogrel (also called PLAVIX)  75 mg p.o. daily, together for a total duration of 3 months.  After 3 months, continue on Aspirin 81 mg orally daily. If you experience any serious bleeding please seek immediate medical attention. For additional information on Antiplatelet medications, and what to expect about the possibility of bruising or minor bleeding, please visit the Heart and Stroke website at: https://www.heartandstroke.ca/heart/treatments/medications/antiplatelet-medications 

[option 6  - for CAROTID ARTERY STENTS - NOTE THER ARE TWO OPTIONS]

Option 6A - 3 MONTHS DAPT and then SAPT

3 months of DAPT and then SAPT - * Specify if stepping down to ASA or Plavix

You have been started on - DUAL antiplatelet therapy for your STENT.  Please continue to take aspirin (also called ASA) 81 mg p.o. daily, along with Clopidogrel (also called PLAVIX)  75 mg p.o. daily, together for a total duration of 3 months. After 3 months, continue on a single antiplatelet agent, which will be either ASA or Plavix - please see you prescription for details. If you experience any serious bleeding please seek immediate medical attention. For additional information on Antiplatelet medications, and what to expect about the possibility of bruising or minor bleeding, please visit the Heart and Stroke website at: https://www.heartandstroke.ca/heart/treatments/medications/antiplatelet-medications 

Option 6B - CONTINUE DAPT until Follow-Up

3 months of DAPT and * TO BE RE-ASSESSED IN CLINIC

You have been started on - DUAL antiplatelet therapy for your STENT.  Please continue to take aspirin (also called ASA) 81 mg p.o. daily, along with Clopidogrel (also called PLAVIX)  75 mg p.o. daily, together until re-assessed in the clinic - please see your prescription for additional details. If you experience any serious bleeding please seek immediate medical attention. For additional information on Antiplatelet medications, and what to expect about the possibility of bruising or minor bleeding, please visit the Heart and Stroke website at: https://www.heartandstroke.ca/heart/treatments/medications/antiplatelet-medications 

[option 7 - Apixaban]

You have been started on - Apixaban (also called ELIQUIS) (LU code 448) You have been started on apixaban, a twice daily oral anticoagulant drug, for stroke prevention in atrial fibrillation.  The standard dose is 5mg twice daily. Good compliance is essential for the drug to be effective. While taking apixaban, renal function should be monitored regularly (at least several times a year) and additionally when clinically indicated.  Apixaban should be used at a reduced dose of 2.5mg BID if 2 out of 3 of the following criteria are present: Age>80; wt<60kg and creat >133umol/L.  Apixaban use is not recommended if eGFR is <25 ml/min. 

For additional information on Anticoagulants, and what to expect about issues such as side-effects, please refer to the following Heart and Stroke website address at: https://www.heartandstroke.ca/heart/treatments/medications/anticoagulants 

[option 8 - Rivaroxaban]

You have been started on - Rivaroxaban (also called XARELTO): (LU code 435) You have been started on rivaroxaban, a once daily oral anticoagulant drug for stroke prevention in atrial fibrillation. The standard dose is 20mg daily. Good compliance is essential for the drug to be effective. While taking rivaroxaban, renal function should be monitored regularly (at least several times a year) and additionally when clinically indicated. Rivaroxaban should be used at a reduced dose of 15mg daily if eGFR is 15-49ml/min.  Rivaroxaban use is not recommended if eGFR is <15 ml/min. 

For additional information on Anticoagulants, and what to expect about issues such as side-effects, please refer to the following Heart and Stroke website address at: https://www.heartandstroke.ca/heart/treatments/medications/anticoagulants 

[option 9 - Edoxaban]

You have been started on - Edoxaban (also called Lixiana): (LU code 554) You have been started on edoxaban , a once daily oral anticoagulant drug for stroke prevention in atrial fibrillation. The standard dose is 60mg daily. Good compliance is essential for the drug to be effective. While taking edoxaban , renal function should be monitored regularly (at least several times a year) and additionally when clinically indicated. Edoxaban should be used at a reduced dose of 30mg daily if eGFR is 15-49ml/min.  Edoxaban use is not recommended if eGFR is <15 ml/min.  In some patients, who are older, frail, and/or have a very high risk of bleeding - you may have been started on a lower dose, 15mg daily.

For additional information on Anticoagulants, and what to expect about issues such as side-effects, please refer to the following Heart and Stroke website address at: https://www.heartandstroke.ca/heart/treatments/medications/anticoagulants 

[option 10 - Warfarin]

You have been started on WARFARIN as a blood thinner, it is quite important that you take your dose daily for this medication. he use of warfarin should not interfere with a healthy diet.  However it is important not to have large day-to-day variations in the amount of vitamin K which is found in foods such as kale, broccoli, spinach, turnip greens, Brussels sprouts.  Therefore it you can eat any of these things however your diet must be consistent in the amount of leafy green vegetables such that the amount of vitamin K is stable because vitamin K reduces the efficacy of warfarin.  For warfarin, your target INR is [FILL TARGET INR] - with a range of [FILL RANGE] -the INR, known as the international eyes normalized ratio, is a way of expressing how thin your blood is, and therefore measurement is required to make sure that your blood is adequately thin while on this medication.  When initially starting on this medication he takes regular blood work, measuring the INR on a daily basis even, as it becomes more stable, weekly or a couple of times monthly is all that is needed to ensure that your INR is within the therapeutic limit.

For additional information on Anticoagulants, and what to expect about issues such as side-effects, please refer to the following Heart and Stroke website address at: https://www.heartandstroke.ca/heart/treatments/medications/anticoagulants 

[IF NEW STATIN START, Include the following and Agent + Dose]

For stroke treatment and prevention, you have been started on the following ADDITIONAL agents: 

You have been started on a statin agent: [PLEASE NOTE STATIN name and dose at QHS]. We request that you follow-up with your family doctor with re-assessment and repeat bloodwork for liver/lipid profiles and CK in 3 months then annually. For Cholesterol and post-stroke risk modification: Your targets are a total cholesterol <4.0 and LDL <2.0.

Treatment with medications such as statins can cause common complaints such as muscle pain.  You may feel pain as soreness, tiredness or weakness in your muscles.  In general the actual risk of developing muscle pain as a result of taking a statin is about 5% or less.  Studies have found that people stop taking this medication up to 30% because of muscle aches even when it was not due to this medication and they were on a placebo medication.  Nonetheless, if you are having severe muscle aches, muscle pain, please see her physician for additional follow-up.  Very rarely statins can cause a life-threatening illness, muscle injury called rhabdomyolysis, which can cause liver damage, kidney failure and even death.  The risk of this very serious side effect is extremely low, it is a few cases per millions of patients, however this is a known risk and you should be aware of it.  Liver damage or injury can occur with statin therapy, however this is again extremely rare, which is why we recommend you follow-up with your family physician in approximately 3 months for follow-up and blood work as outlined above.

[ACEI / ARB / Diuretics]

Please see your family doctor - suggest monitoring of electrolytes and Creatinine when started on medications belonging to the class of ACEi (ACE Inhibitors)/ARBs (Angiotensin receptor blockers) and diuretics ("water pills").

[PENDING INVESTIGATIONS]

2) Investigations pending - the following tests are pending:

Labwork (A1C, Lipid Profile)
Hypercoaguable screening
Auto-immune serology
CT
CT angiogram
MRI brain
MR angiogram
MR venogram
MR vessel wall imaging
Carotid dopplers
Transcranial dopplers for micro-emboli detection
TTE (Trans-thoracic Echocardiogram)
TEE (Trans-esophageal Echocardiogram
24-48 hour Holter monitoring
Prolonged Holter monitoring
Overnight Polysomnogram (sleep study)
EEG
EMG/NCS
Brain SPECT

3) Driving information:

[option 1- DO NOT DRIVE for 1 month
- ALL patients - Instructed not to drive for 1 month -
and NOT Reported to the Ministry of Transportation]

In accordance with the medical advice provided, you are required to refrain from driving for a duration of one month. It is advised that you schedule a follow-up appointment with your family doctor in line with the outlined recommendations. Moreover, you may also be assessed at a stroke prevention clinic as detailed below. Should you be unable to secure an appointment within the one-month timeframe or upon its completion, please consult your primary care physician before resuming any driving activities. Under the guidance provided in July 2018 by the Ministry of Transportation, there is no current requirement for reporting using the Medical Condition Report. If you need corrective lenses while driving, it is crucial to use them consistently when operating a vehicle. If your medical condition changes or if you encounter new or additional medical issues or concerns, then it is essential to seek a physician's assessment regarding your driving ability. Until the assessment is complete, please abstain from driving. In the instance of any stroke-like symptoms reappearing, promptly consult a physician and avoid driving for an additional month until a medical professional reevaluates your condition.

[option 2 - REPORTED to MOT - Reported to the Ministry of Transportation]

You are instructed not to drive due to your neurologic-related condition (which may involve motor or physical impairment, cognitive impairment, visual field impairment, or increased risk of stroke). Your physician team has reported you to the Ministry of Transportation, as mandated by law, due to concerns about the potential risk of a motor vehicle accident or the safety of yourself and others while operating a motor vehicle. Please refrain from driving until you have been reassessed at a designated stroke prevention clinic, by your family doctor, or another physician willing to assess you and communicate with the Ministry of Transportation. Once you have received the appropriate forms from the Ministry of Transportation and your medical condition is deemed stable, any of several qualified healthcare professionals can complete the necessary paperwork on your behalf to re-gain driving status (family physician, stroke physician, other medial physician specialists). This ensures both your safety and the safety of others while operating a motor vehicle.

4) Stroke-Specific Follow-up Plan:

Stroke prevention clinic appointment Date: 

[option 1 - LOCAL Hospital]

Stroke Prevention Clinic will be arranged for you on discharge and the clinic will be in touch regarding your appointment. If you have not heard back within 1-2 weeks, please get in touch with the Rapid TIA Stroke Clinic, at SHSC, A233-2075 Bayview Ave, Toronto, ON M4N 3M5. Tel. 416-480-6100, x. 89124 ; Fax. 416-480-4833

[option 2 - at the Patient's Home Hospital - for patient's being Repatriated]

Stroke Prevention Clinic at your Home Hospital: Your stroke follow-up will be arranged for you on discharge from your home hospital. At the time of discharge from our institution you are being transferred to your home hospital. For convenience we have listed the contact of your destination hospital's Stroke/TIA Prevention Clinic:

[option 3 - MacKenzie Hospital]

MACKENZIE HOSPITAL: Mackenzie Health, 10 Trench St., Richmond Hill, ON L4C 4Z3, The Clinic will attempt to contact you with the date and time of your appointment within 1-3 business days following your visit to the emergency department or Family Doctor. If you do not hear from the Stroke Prevention Clinic within 1 week from discharge, or you miss our call, please call the clinic at: (905) 883-1212 x7721 from Monday to Friday, 8am to 4pm

[option 4 - North York General]

NORTH YORK HOSPITAL: Stroke Prevention Clinic, The key focus of the Stroke Prevention Clinic is secondary stroke prevention and health promotion. The clinic addresses risks and provide early intervention and education to patients. A nurse practitioner works alongside neurologists to provide care for stroke patients. Our goal is to manage the growing incidence of stroke in the community by improving the patient's quality of life through education, treatment and support. General site,  Tel: 416-756-6000   4001 Leslie Street, Toronto ON M2K 1E1