PATH Clinic2

PATH    CONSULTATION
MRN: [text]

[text name="variable_1"] is    a    [text]yo   with    a    diagnosis    of    [text]. [var name="variable_1"]  was    assessed    by    the    Palliative    and    Therapeutic    Harmonization    service    on    [date name="dateofencounter" default=""].

SDM: [text]

GOC: [text]

Collateral   obtained    from:     [text]

Reason    for    Referral: [checkbox value="Goals    of    care|Procedure/intervention    and    goals    of    care    discussion|Cognitive    concerns"][textarea]

Past    Medical History
[checkbox value="HTN|DMII|DLP|Hypothyroidism|BPH|AFib|CHF|Asthma|COPD|OSA|CKD|IHD"][textarea]
Past    Surgical    History
[textarea]
Details    of    Relevant    Hospitalizations
[textarea]

Current    Medications:    See    CoCGA    for    details.    [textarea]

Allergies: [text default="NKDA. No known food or environmental allergies."]

Social    History:
[var name="variable_1"]    lives    [select name="livingcondition" value="alone|with    *******"]    in    a    [select name="living" value="house|apartment/condo|independent    living    facility|LTC"].    The    family    is    [select name="familyinvolvement" value="involved.|not    involved."]The patient    is    [checkbox name="occupation" value="a    retired    *******|currently    employed,    working    as    ******|on    disability"].    [var name="variable_1"]    has    [select name="numberofchildren" value="no|1|2|3|4|5|6"] children.    They    [select name="religion" value="are    not    religious    or    spiritual|identify    as"].
[select name="nicotine" value="The patient    is    a    lifelong    non-smoker.|The    patient    is    an    ex-smoker,    ******|The    patient    is    currently    smoking    ******"].    There    is    [select name="cannabis" value="no    reported    cannabis    use.|occasional    cannabis    use,    *******.|regular    cannabis    use,    *******."]    The    patient    endorses    [select name="ETOH" value="no    current    or    historical    ETOH    use|no    current    ETOH    use,    with    a    remote    history    of    ETOH|current    ETOH    use,    approximately    ******|a    history    of    heavy    ETOH    use    ******"].    There    is    no    other    reported    substance    use.
[var    name="variable_1"]  [checkbox name="CCNS" value="does    not    have    any    CCNS    supports    at    this    time.|has    VON    q******,    for    ******.|receives    assistance    in    the    home    via    ******."]

History    of    Presenting    Illness
[textarea name="history" default=""]

Physical    Examination
General:    [checkbox name="GeneralExam" value="Appears    well,    NAD.|Appears    uncomfortable.|Somnolent."]
Vitals: [textarea name="vitals" default="height ******, weight ******, BP ****** mmHg, Pulse ****** bpm ***regular/irregular***, RR ****** respirations/minute, Temp ******" fillable="true"]
Neuro:
-    Cranial    nerves:    [checkbox name="CN" value="II-XII    within    normal    limits,    VIII    not    formally    tested.|Abnormal  testing,    ******."]
-    Cerebellar    testing:    [checkbox    name="cerebellar"    value="RAM    and    finger-to-nose    normal.|Abnormal    testing,    ******."]
-    Reflexes:    [checkbox name="reflexes" value="Normal,    2+   at    the    brachioradialis,    biceps,    patella,    and    achilles.|Diminished    at    the    ******,|Otherwise,    normal    and    symmetrical    reflextes    in    the    upper    and    lower    extremities."]
    Tone:    [checkbox name="tone" value="Normal    tone    in    the    bilateraly    upper    and    lower    extremities.|Facilitatory    paratonia    noted    ******.|Cogwheeling    rigidity    noted    ******."]
-    Strength    testing    was    ******/5    in    the    upper    extremities.
-    Strength    testing    was    ******/5    in    the    lower    extremities.
-    Sensation  [checkbox name="sensation" value="grossly    intact     to    the    distal    upper    and    lower    extremities.|diminished    to    crude    touch    in    the    ******.|not    formally    assessed."]
-    Gait    observed,    [checkbox name="gait" value="within    normsl    limits.|slowed.|ataxic.|antalgic.|shuffling."]

CVS:    [checkbox name="CVS" value="S1S2    audible    without    murmur.|S1S2    audible,    +murmur    ******.|No    pedal    edema.|Pedal    edema    to    the    lower    extremities    bilaterally.|Normal    capillary    refill.   |Abnormal    capillary    refill."]

Resp:[checkbox name="resp" value="Good    AE    bilaterally    to    the    bases    without    adventitious    sounds.    No    increased    WOB.|Adequate    AE    bilaterally    to    the    bases.|No    adventitious    sounds.|Crackles    present    ******.|Wheeze    noted    ******.|No    increased    WOB.|Increased    WOB,    ******."]

Relevant    Investigations: [textarea]

Cognitive    Testing    and    History
MMSE:    [text name="MMSE" default="/30"]
-    Recall    scored    at    [text name="MMSErecall" default="/3"]
FAB:    [text name="FABscore" default="/18"]
BCRS:    [select name="BCRS" value="Mild|Moderate|Severe"]

Timeline    of    concerns    regarding    cognition:    [text name="cognitiontimeline" default=""]
In    terms    of    risk    factors,    there    [select name="riskfactors" value="is    no|is    a   "]    history    of    alcohol    use    disorder,    stroke,    cardiac    disease,    vascular    disease,    or    atrial    fibrillation.
[checkbox name="memory" value="There    are    no    concerns    regarding    the    patient's    memory.|There    are    challenges    with    the    patient's    short    term    memory.|There    is    reported    difficulty    with    remembering  conversations/facts.|Collateral    notes    repetitive    questions    and    comments.|The    patient    will    often    forget    names."]    [checkbox name="language" value="There    are    no    challenges    with    word    finding    or    language.|There    are    reported    issues    with    the    patient's    word    finding    ability.|There    has    been    a    change    in    reading    ability.    There    is    aphasia.    There    is    dysarthria."]  [var name="variable_1"] [checkbox name="orientation" value="does    not    miss    appointments    or    forget    dates.|will    forget    dates    and    miss    appointments."]    Collateral    notes    the    patient    [checkbox name="visuospatial" value="does    not    wander    or    get    lost.|wanders and    will    get    lost    at    times."]    There    [checkbox name="execfxn" value="no    history    of|a    history    of"]    problem    operating    devices.    Mood    is    described    as    [checkbox name="mood" value="normal.|low.|apathetic."]    Collateral    has    [checkbox name="behaviour" value="not    noticed    any    changes    to    the    patient's    behaviour.|describes    a    personality    change.|endorses    a    history    of    irritability.|describes    concerns around    hallucinations/delusions."]

Functional    Inquiry

At    baseline,    [var name="variable_1"] [select name="ambulation" value="is    independently    ambulatory.|requires    a    standby    assist.|needs    assistance    to    ambulate.|non-ambulatory."]    Currently,    they    are    [select name="currentambulation" value="independent.|standby    assist.|requiring    assistance    x    ******.|non-ambulatory."]
At    baseline,    the    patient[select name="gait" value="does    not    use    a    gait    aid.|uses    a    cane. |uses    a    walker.|uses    a    wheelchair."] Currently,    they    are    [select name="gaitaid" value="not    using   a    gait    aid.|using    a    cane.|using    a    wheelchair.|using    a    walker."] 

There    are    [select name="falls" value="no|1-2|2+"]    reported    falls    in    the    last    6    months.  

There    [checkbox name="Weight" value="are    no    reported    changes    to    weight.|is    reported    weight    gain|is    reported    weight    loss,    estimated    at    *******    in    a    ******    timespan."]    The    patient's    appetite    is    reportedly    [checkbox name="appetite" value="unchanged|decreased|increased"].
[select name="continence" value="There    are    no    issues    with    bowel    or    bladder    continence.|There    is    bladder    incontinence,    ongoign    since    ******.|There    is    bowel    incontinence,    ongoing    since    ******.|There    is    bowel    and    bladder    incontinence.    This    is    ongoing    since    ******"]    There    [checkbox name="visionhearing" value="is    no functional    impairment    of    hearing    or    vision.|is    impairment    of    vision,    ******.|is    impairment    of    hearing,    ******."]
[select name="skinbreakdown" value="There    are    no    issues    with    skin    breakdown.|There    are    concerns    with    skin    breakdown,    ******."]
[select name="pain" value="The    patient    experiences    pain    ******|There    is    no    reported    pain.="]

Impression    &    Recommendations: [textarea]

I    will    review    the    above    in    detail    with    my    staff    physician,    [select name="StaffPhysician" value="Dr.    Mallery.|Dr.    Moorhouse.|Dr.    Rogers."]
Thank    you    for    the  referral    and    the  opportunity    to    be    involved    in    this    patient's    care.

Maya    Kovacs,    PGY-3    
Palliative    Medicine