PALLIATIVE MEDICINE CONSULTATION NOTE
@TD@
Referring Physician: @ATTPROV@
Reason for Consult: Goals of care/symptom management***
Date of Admission: @ADMITDT@
Hospital Length of Stay: @IPLENGTHOFSTAY@
History of Present Illness:
@NAME@ is a @AGE@ @SEX@ that @PMHPPOS@ Patient was admitted to the hospital for ***
Review of Systems:
Edmonton Symptom Assessment Scale (ESAS)
Pain ***/10
Fatigue ***/10
Drowsiness ***/10
Nausea ***/10
Depression ***/10
Anxiety ***/10
Dyspnea ***/10
Appetite ***/10
Well-being ***/10
Sleep ***/10
Spiritual Distress: ***
Financial Distress: ***
Other:
Constipation: ***
Diarrhea: ***
Falls in last 3 months: ***
MEDD: ***
Opioid Induced Neurotoxicity: There are *** signs of OIN.
Memorial Delirium Assessment Scale (MDAS):
Awareness: ***
Disorientation: ***
Short-term memory: ***
Digit Span: ***
Attention: ***
Disorganized Thinking: ***
Perception: ***
Delusions: ***
Psychomotor: ***
Sleep/Wake Cycle: ***
TOTAL: ***/30
(>7 abnormal for cancer patients, >13 abnormal for non-cancer patients)
Grade ECOG (Eastern Cooperative Oncology Group)
0 Fully active, able to carry on all pre-disease performance without restriction
1 Restricted in physically strenuous activity but ambulatory and able to carry out work of a light or sedentary nature, e.g., light house work, office work
2 Ambulatory and capable of all selfcare but unable to carry out any work activities. Up and about more than 50% of waking hours
3 Capable of only limited selfcare, confined to bed or chair more than 50% of waking hours
4 Completely disabled. Cannot carry on any selfcare. Totally confined to bed or chair
5 Dead
Allergies:
@ALLERGY@
Current Medications:
@MEDSCURRENT@
@PMH@
@PSH@
@FAMHX@
@SOCDOC@
Physical Exam:
@VITALS@
General: NAD
Eyes: Pupils are equal, round, and reactive to light. No scleral icterus.
Mouth: Moist mucus membranes with no signs of mucositis.
Neck: Supple.
Lungs: Clear to auscultation bilaterally.
Heart: Regular rate and rhythm. No M/R/G.
Abdomen: Soft, non-tender with no guarding or rebound, non-distended, normoactive bowel sounds.
Musculoskeletal: No obvious deformity.
Skin: Warm and dry. No rash. No jaundice.
Neuro/Psych: Alert and oriented x 3. No myoclonus. Speech is clear and coherent. Normal affect.
Extremities: *** edema
Labs:
@CRCL@
Imaging:
***
Assessment and Plan:
@NAME@ is a @AGE@ @SEX@ ***. Palliative medicine was consulted for symptom management and goals of care.
-Goals of Care/Advance Care Planning: Long supportive conversation held with patient. We discussed ***
MPOA:***
Relation: ***
Phone: ***
Code Status: ***
30 min spent on ACP conversation.
- Cancer-related pain in the ***: Nociceptive-***, neuropathic component-***. No signs of chemical coping or addictive behaviors.
- Delirium: ***. Patient is at high risk for developing hospital delirium given age, frailty, and comorbidities.
Recommend treating all reversible etiologies of delirium (hypoxia, infection, opioid-induced neurotoxicity, etc.)
Open blinds during day, close at night. Avoid frequent interruptions in the nighttime. Ensure visible presence of clock and calendar in room. If hearing aides/dentures used, ensure patient is provided.
- Shortness of Breath: 2/2 ***. Opiates as above.
- Nausea/Appetite/Early Satiety: Encouraged frequent, small meals. ***.
- Slow-transit Constipation Prophylaxis: Opioid induced. Recommend using a combination of senna (2-8 tabs daily) and miralax (daily to bid). Titrate up prn to achieve daily soft BM.
- Insomnia: Encouraged sleep hygiene. ***.
- Cancer-related Fatigue/Deconditioning: Recommend increased physical activity and visual sunlight exposure. PT/OT consulted***
-Depression:
-Anxiety:
- Psychosocial and Emotional: Expressive support provided. ***.
Thank you for this consult. Palliative medicine will continue to follow.