in-patient progress note

Impression:


Plan:

  • Stroke Etiology:
  • Stroke medical treatment:
    • ASA Started
    • Started on DAPT (dual anti-platelet therapy)
    • Started on Heparin (UFH) | Started on LMWH
  • Stroke work-up:
    • Lipid panel performed. Patient is started on a Statin.
    • ECHO:
    • Holter:
  • Stroke workup - Imaging:
    • Repeat CTA:
    • MRI:
  • Driving:
    • We will fill out a Ministry of Transportation (MoT) Medical Condition Report (July 2018 version) and the patient is aware not to drive and that reporting will be completed.
    • This patient does not require reporting to the MoT (Medical Condition Report, July 2018 version) at this time given absence of motor (physical impairment), cognitive impairment, or visual field impairment.
  • Family/Patient Update: Discussion with the patient/SDM regarding findings and the treatment plan including other options (risks, benefits, alternatives). Discussed risks of bleeding with regards to ASA/Anticoagulation. Discussion occurred using lay language. All questions answered.