progress note
suggestions

Profile:
-

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:

-

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:
-
-
-
-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.

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.

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.

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.

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