Palliative Consult:
Patient ID:
78-year-old female, diagnosed with metastatic breast cancer
Reason for Consult:
"Pain and symptom management"
History of Present Illness (HPI):
The patient presents with worsening pain in the lower back and difficulty sleeping due to discomfort. She reports increased fatigue and occasional nausea. The patient has a history of breast cancer diagnosed 5 years ago, with metastasis to the bone. She has undergone chemotherapy and radiation therapy in the past. Currently, she is taking morphine for pain management and ondansetron for nausea. She lives with her daughter, who is her primary caregiver.
Past Medical History (PMHx):
Breast cancer diagnosed in 2018, hypertension since 2010, osteoarthritis diagnosed in 2015
Medications:
Morphine 15 mg every 4 hours, Ondansetron 8 mg as needed, Lisinopril 10 mg daily
Allergies:
No known drug allergies
Preferred Pharmacy:
Green Valley Pharmacy
Palliative Review of Systems (ROS):
Pain: Severe lower back pain
Nausea: Occasional
Shortness of breath: None
Mood: Depressed
Appetite: Decreased
Functional status: Limited mobility
Bowel movements: Regular
Bladder function: Normal
Social History:
The patient lives with her daughter in a single-family home. She has a strong support system from her family and attends a local church. She has Medicare insurance and receives home care services twice a week.
Code Status:
Do Not Resuscitate (DNR)
Objective:
The patient appears frail and in moderate distress due to pain. Vital signs: BP 130/80, HR 88, Temp 98.6Β°F. Physical examination reveals tenderness in the lumbar region. Recent imaging shows progression of bone metastasis.
Assessment:
The patient has metastatic breast cancer with significant pain and decreased quality of life. Primary diagnosis: Metastatic breast cancer. Secondary diagnosis: Chronic pain. Palliative Performance Scale (PPS) score: 50%
Plan:
Continue current pain management regimen with morphine. Consider increasing dosage if pain persists. Initiate palliative care consultation for additional support. Discuss goals of care and advance care planning with the patient and family. Schedule follow-up in two weeks. Provide education on pain management and coping strategies to the patient and family.
Palliative Consult:
Patient ID:
[patient's age, gender, diagnosis]
Reason for Consult:
"Pain and symptom management"
History of Present Illness (HPI):
[Current issues, reasons for visit, discussion topics, history of presenting complaints, if mentioned]
[Past medical history and previous surgeries, if applicable]
[Medications and herbal supplements currently in use]
[Relevant social history, such as living arrangements, support system, and lifestyle, if provided]
[Allergies, if mentioned]
Past Medical History (PMHx):
[List of previous medical conditions, including dates where available]
Medications:
[List of medications, including dosage and any recent changes]
Allergies:
[List allergies, if applicable]
Preferred Pharmacy:
[Pharmacy name]
Palliative Review of Systems (ROS):
[Pain, if mentioned]
[Nausea, if mentioned]
[Shortness of breath, if mentioned]
[Mood, if mentioned]
[Appetite, if mentioned]
[Functional status, if mentioned]
[Bowel movements, if mentioned]
[Bladder function, if mentioned]
Social History:
[Include details such as living arrangements, support structure, religious beliefs, family contacts, housing, insurance, affordability of care, and home care services, if mentioned]
Code Status:
[Patient's code status]
Objective:
[General appearance and overall condition]
[Vital signs, if provided]
[Physical examination findings, if mentioned]
[Laboratory and imaging results, if available]
Assessment:
[Summary of the patient's condition and prognosis]
[Primary and secondary diagnoses]
[Palliative Performance Scale (PPS) score]
Plan:
[Treatment plan, including medications, therapies, and other interventions]
[Goals of care and advance care planning]
[Follow-up plans and referrals, if mentioned]
[Patient and family education and support provided]
(Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care - use only the transcript, contextual notes or clinical note as a reference for the information included in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes or clinical note, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or section blank.)
