What is the easiest way to write a progress note in Transient Ischemic Attack (TIA)?

Streamlined Progress Note Structure for TIA

Use a focused, problem-oriented format that documents risk stratification, diagnostic workup completion, etiology determination, and treatment initiation—this is the most efficient approach for TIA documentation.

Essential Components to Document

Risk Stratification (Document First)

• Calculate and document ABCD2 score explicitly (Age ≥60 years=1, BP ≥140/90=1, Clinical features: unilateral weakness=2 or speech disturbance without weakness=1, Duration ≥60 min=2 or 10-59 min=1, Diabetes=1) 1, 2
• High-risk patients (ABCD2 ≥4) face 8% stroke risk at 2 days versus 1% in low-risk patients 1
• Document time from symptom onset to presentation (critical for treatment decisions) 1, 2

Clinical Presentation Details

• Specify vascular territory: Document whether symptoms suggest anterior circulation (carotid territory: unilateral weakness, aphasia, monocular vision loss) or posterior circulation (vertebrobasilar: ataxia, cranial nerve deficits, bilateral symptoms) 3
• Duration of symptoms: Typical TIA lasts <15 minutes, though definition allows up to 24 hours 3
• Document complete resolution of symptoms 4

Diagnostic Workup Status

• Brain imaging completed: CT or MRI to exclude hemorrhage and identify acute infarction 3, 1, 2
• Vascular imaging: Carotid Doppler for anterior circulation symptoms; CTA or MRA from aortic arch to vertex for comprehensive assessment 1, 2
• Cardiac evaluation: ECG completed, rhythm monitoring status, echocardiography if indicated 3, 2
• Laboratory results: CBC, electrolytes, creatinine, fasting glucose, HbA1c, lipid profile, coagulation studies 3, 2

Etiology Determination

• Document suspected mechanism: Large artery atherosclerosis (carotid stenosis %), cardioembolic (atrial fibrillation, valvular disease), small vessel disease, or cryptogenic 3, 2
• For carotid stenosis, document exact percentage if known (critical for surgical decision-making) 3

Treatment Initiated

• Antiplatelet therapy: For non-cardioembolic TIA, document dual antiplatelet therapy (aspirin plus clopidogrel for 21 days) if high-risk, or single agent if lower risk 1, 2
• Anticoagulation: For cardioembolic source (atrial fibrillation), document initiation of oral anticoagulation with target INR 2.0-3.0 3, 2
• Statin therapy: Initiated regardless of baseline cholesterol 1
• Blood pressure management: Target <130/80 mmHg, typically wait 7-14 days before starting antihypertensives unless severely elevated 3, 1

Disposition and Follow-up Plan

• High-risk patients (ABCD2 ≥4): Admit to stroke unit for continuous monitoring 1, 2
• Low-risk patients (ABCD2 <4): May be managed outpatient with neurology follow-up within 7-10 days 2
• Urgent surgical evaluation: If symptomatic carotid stenosis >70%, document vascular surgery consultation for endarterectomy within 2 weeks 3, 1, 2
• Document neurology follow-up arranged within 2 weeks with clear medication instructions 1, 2

Common Pitfalls to Avoid

• Don't delay imaging: Brain and vascular imaging must be completed urgently, ideally within 24 hours 3, 1, 2
• Don't miss carotid stenosis: Failure to obtain vascular imaging delays potentially life-saving endarterectomy, which loses benefit after 2 weeks 3, 2
• Don't forget medication reconciliation: Document herbal supplements (feverfew, garlic, ginkgo biloba, ginger, ginseng) that interact with anticoagulants 3, 2
• Don't overlook amaurosis fugax: Transient monocular blindness is a TIA variant strongly associated with ipsilateral carotid disease 2
• Don't discharge high-risk patients: ABCD2 ≥4 requires admission regardless of symptom resolution 1, 2

Time-Saving Documentation Strategy

Use a template with pre-populated fields for ABCD2 calculation, imaging checklist, and treatment algorithm based on etiology 5, 6. This ensures completeness while minimizing documentation time and supports communication with other clinicians 5, 7.