progress note
suggestions

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 Medicine 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.

[Note may be dictated using AI technology (Dragon Medical One). Not fully proofread; may be edited further. For errors or clarifications, please contact author and/or staff directly.]

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.

A comprehensive medical update was provided to the patient regarding their current condition, diagnostic findings, and proposed treatment plan. All discussions were conducted using clear, plain language to ensure patient comprehension. The patient was given ample opportunity to ask questions throughout the conversation, and all inquiries were addressed thoroughly and to the patient's expressed satisfaction. The risks, benefits, and alternatives of the proposed interventions were explained in detail. The patient demonstrated understanding of the information provided by accurately summarizing key points. It was emphasized that the patient should seek clarification on any aspect of their care at any time. The patient verbally confirmed their satisfaction with the explanations given and the proposed course of action.

A detailed medical update was provided to the patient's substitute decision-maker (SDM) regarding the patient's current clinical status, relevant test results, and recommended treatment plan. All information was conveyed using clear, non-technical language to facilitate comprehension. The SDM was actively encouraged to ask questions throughout the discussion, and all inquiries were addressed comprehensively. The potential risks, benefits, and alternatives of each proposed intervention were explained thoroughly. The SDM demonstrated understanding by restating key information in their own words. It was emphasized that the healthcare team is available for any future questions or concerns. The SDM verbally expressed satisfaction with the information provided and the answers given to their questions. The SDM's role in the decision-making process was clearly explained, and they were informed of their right to request additional information at any time.

CLINICAL PLAN FOR HOME HOSPITAL:

-Admit

-Consult Internal medicine

-Consult neurology, if ongoing deficits concerning for stroke

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

-Repeat Imaging - CT head in 24H and/or MRI brain to rule out infarct and/or assess for evolution of changes; proceed with stroke workup as applicable, including metabolic profile, 2D ECHO, Holter and/or Telemetry. Tests at the discretion of Emergency Medicine/Internal Medicine/Neurology as applicable

-Medical issues:

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

NEUROVASCULAR SURGERY DISCHARGE INSTRUCTIONS:

- You have been started on:
- DUAL antiplatelet therapy for your: [ ]
- SINGLE antiplatelet therapy for your: [ ]

- Please continue to take your above antiplatelet agents until re-assessed in the Neurovascular clinic with Dr. [ ].
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.

- Do not Stop antiplatelet medications unless told by office of Dr. [ ].

- Can take shower. Do not submerge / bath / swim for 2 weeks. 

- Walk slow and progressively increase pace over 2 weeks. 

- No vigorous activity till 2 weeks post procedure. 

- 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).

- Groin care: Post groin puncture concerns like hematoma (bruise), groin bleed, local swelling to be evaluated with Ultrasound. 

- Stroke like symptoms needs to be escalated to higher center. Please call Sunnybrook Hospital via CRITICALL.