progress note
suggestions

Progress Note

Profile:
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Patient seen and reviewed in person during bedside Stroke Team rounds.
Overnight issues, as applicable, reviewed.
Vital sign values in AM rounds reviewed.
Labs (recent) reviewed .
Medications reviewed - daily review.
Imaging (recent) reviewed.

Exam and Relevant findings/Ix:

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Discussed in Stroke multidisciplinary rounds, 0930-0945; Then 0945-1010 AM with Orange team colleagues for NVU Level 1 patients. Present were team members, including team lead, SW, OT, PT, SLP, MD (staff, fellow, residents as applicable). Discussed clinical status, discussed disposition planning.

CLINICAL PLAN:
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-Medical care: DVTp, Diet, and Activity plan reviewed, Allied Health Team (members as applicable, SW, PT, OT, SLP, Dietician) implementing their assessment-based plan; please see their notes for additional details.

Detailed Impression and Plan

IMPRESSION:


PLAN:

Patient Update

All discussions occurred using clear language and plain terms, opportunity was provided for the patient to ask questions, and their questions were answered, they were satisfied with the answers provided.

SDM Update

All discussions occurred using clear language and plain terms, opportunity was provided for the SDM to ask questions, and their questions were answered, they were satisfied with the answers provided.

Repatriation Plan

HOME HOSPITAL CLINICAL PLAN:

-Admit

-Consult Internal medicine

-Consult neurology, if ongoing deficits concerning for stroke

-Please rule out co-present medical issues such as ischemia, sepsis, metabolic abnormalities

-Repeat Imaging - CT head in 24H or MRI brain to rule out small stroke; with stroke workup as applicable, including metabolic profile, MRI, 2D ECHO. Tests at the discretion of Internal Medicine/Neurology

-Medical issues:

-Call back Sunnybrook Stroke if any questions or concerns; stroke on-call