Scripts Flashcards
Primary inpatient issue
(9 points)
“He has been an inpatient since … or for … days after being BIBA following..
[symptom] over [timespan] with associated [symptom]
Severity of symptoms, frequency etc.
“This has been interfering with his ability to [dress,drive, shower, work, walk, write, prepare meals, etc.]
“He has been treated for presumed X on the basis [Known tests] which I will need to confirm” OR “Pt reports treatment for X which is discordant with current therapy”
“Although unclear to the patient, I presume/wonder about the dx of X” or “management of X”
“He is currently improving on [treatment], awaiting [GEM/rehab/discharge] on the basis of” OR “Pt is not reporting improvement
Further inpatient complications [AKI, pain, infection, post operative issues, deconditioning requiring rehab, etc]
Relevant negatives
Outpatient key issues - cardioresp
“Several months of exertional/sporadic ischemic/non ischemic pleuritic chest pain involving [area of chest] radiating to X”, “Occuring X times per day/week/month with an increasing frequency”
” X month/week Hx of progressive dyspnoea with a X metre ET w/assoc. [noctural wheeze]/3 pillow orthopnoea]/[productive or non productive cough]
“X month Hx of High/low volume haemoptysis expectorating X mLs and associated [green/clear/yellow] sputum”
“X months of intermittent/frequent self limiting palpitations lasting X seconds w/ or w/o presyncope/dizziness or LOC
“Cardiovascular risk factors include HTN, T2DM, dyslipidaemia, smoking, FHx of premature CAD, IHD, ESRF, chronic inflammatory disease, OSA/obesity”
“Risk factors for PE include prior DVT/PE, FHx, prior surgery/immobility, long haul travel/car trip,OCP, malignancy”
“He reports recent coryzal symptoms/prior antibiotic therapy for the past X weeks from local medical officer”
Key issue - systemic features
Mr X presents X%/kg weight loss over with a X [time] with associated anorexia/loss of appetite and [night sweats] with associated fatigue/loss of energy despite optimal sleep
He describes [intermittent] fevers/chills/rigors
There are no focal infective symptoms / also describes [cough/dyspnoea,dysuria/frequency, headaches/neck pain, joint pain, change in bowel habits]
Nil malaena/haemoptysis/blood in urine/stools
Nil recent overseas travel, sick contacts, animal contacts, IVDU, recent sexual history
Nil personal or family history of cancer, renal disease or CTD, normal endoscopic, mammogram or cervical screening
Minimal etOH, 50yr ex smoker
Key issue - Infective
“Patient describes productive/non productive cough with [colour] expectorant for X weeks w/ occasional/no haemoptysis”
“He reports intermittent/refrequent painless haematuria / haematuria w/ associated dysuria [and loin pain] with..”
“Increased urinary frequency and urgency OR lower urinary tract symptoms” OR obstructive urinary symptoms”
“Nil fevers/chills/sweats shakes”
“Nil recent sick contacts, overseas travel, IVDU, animal contacts, recent procedures”
“There are no joint or cardiac prostheses”
Key issue - diarrhoea/abdopain
“Mr. X complains several months of high/low volume floating/non floating/”watery”/”bloody” frequent bowel motions of X times per day, w/ or w/o associated noctural diarrhoea/tenesmus/anal pain/incontinence and w/ or w/o associated blood or mucus; there is no associated weight loss or appetite
“X months/weeks of constant/intermittent sharp/dull/colicky [location] abdominal pain [of increasing frequency] radiating to the back/groin
“X months/weeks of progressive/intermittent/stable oropharyngeal/ oesophageal dysphagia for solids or solids or liquids with/without associated odynophagia, post prandial chest pain/NV, regurgitation
“Associated weight loss/LOA, NV
Known disease issue
[symptoms] for several months OR recurrent hospitalisation with [symptom] and confirmed after [investigation] OR specialist review
(investigations if recent/uncontrolled or predominant)
This is in the setting of [known family history], risk factors [CV risk factors, smoking, alcohol, IVDU], known cause of renal disease or cirrhosis or lung disease
Currently complains of [symptom], predominant symptoms have progressed despite therapy/varied throughout years
“He is currently managed with [pharm], requiring [changes to dose] OR on [stable dose] and reports good/poor efficacy”
“Other treatment includes”
“Complications include
Neuro complaint - limbs
“Mr. X complains of a sudden onset/gradual onset progressive fluctuating/constant frontal/temporal/occipital/cervicogenic headache of severe instensity worsening with lying/coughing/standing with associated [photophobia/NV/sonophobia with/without prodromal visual scintilation/aura”
“Complaining of months/weeks/days of progressive/stable patchy/glove stocking/migrating/ascending paraesthesias of arms and feet with associated ataxia”
“Complaining of unilateral/bilateral paraesthesia over the [X dermatome] with associated hyperalgesia”
“Sudden onset/transient painless/painful monocular/binocular temporal/nasal field vision loss w/ w/o prior visual scintillation
“Complaining of X months of progressive/flutuating weakness involving X limb(s) followed by Y limbs with the inability to walk/climb/stand/lift/write/[patient experience] requiring [aid] w/ associated bulbar”
“X months/days of progressive/stable/fluctuating [fatigable] is Symmetric/asymmetric/proximal/distal weakness w/ or w/o bulbar involvement OR isolated [limb] weakness
“Unilateral [upper motoneuron/LMN predominant] paresis/paraplegia w/ ipsilateral/contralateral/dissociated sensory loss w/ wo concominant bilat/contralat/ipsil ataxia
Rheum complaint
“Mr. X complains of several months of painful non-deforming/deforming symmetric/asymmetric migrating mono/oligo/polyarthritis predominantly involving hands/feet with associated/no associated systemic symptoms or extra-articular manifestations”
“Extra-articular manifestations include [uveitis/psoriatic rash/gouty tophi/nodules]
Neuro complaint - head
“Mr. X complains of a sudden onset/gradual onset progressive fluctuating/constant frontal/temporal/occipital/cervicogenic headache of severe instensity worsening with lying/coughing/standing with associated [photophobia/NV/sonophobia with/without prodromal visual scintilation/aura”
“Complaining of sudden onset/gradual persistent/fluctuating/movement induced [debilitating] vertigo/axial instability/non-specific/postural dizziness w/ associated [bil/uni] [left/right] ataxia w/o ipsilateral ear fullness/hearing loss/tinnitus/ear pain
“Transient prolonged/self limiting LOC/syncope w/o w prodrome and post ictal confusion
“[Refractory] [isolated] focal/generalised [T/C T/At C] seizure [of the face/(L or R) limb] w/ w/o preserved awareness w/ w/o associated prodrome / associated aura w/ w/o post ictal Todd’s”
“X months of [unilateral/bilateral movement induced/action] tremor w/o associated [rigidity], festinating gait, cogwheeling ataxia, postural instability
“Sudden onset/transient painless/painful monocular/binocular temporal/nasal field vision loss w/ w/o prior visual scintillation
“Isolated [X] l[pupil sparing] left/right/bilateral occulomotor/trochlear/abducens nerve palsy / complex ophthalmoplegia involving the left/right
“horizontal/vertical diplopia w/ associated …
“Facial asymmetry w/ w/o forehead sparing and associated Bell’s phenomenon
COPD/Asthma/Bronchiectasis/ILD - major issue
Mr.. Has a X year history of [O2 dependent] [end stage/advanced] [well controlled/brittle] [progressive] COPD/asthma/ILD
Risk factors include X pack years/recurrent pneumonia/childhood pneumonia/pertussis/ atopy/childhood eczema/CTD/occupational exposure
If new Dx.. recently confirmed on PFTs/CT/etc.
If old Dx.. “progressive reduction [lung function] w current FEV/FER is.. FVC.. CT changes” OR current lung function which has been stable for X years; ABG result
“dismal/poor ET of X metres w/ associated chronic productive cough” noctural dyspnoea/cough, requiring assistance, unable to…; [lost work school time]
“X [COPD/asthma related] hospitalisations w/o ICU admissions w/ [triggers a,b,c] inducing flare/exac, recurrent pneumonia w/ known [X] colonisation
“limited insight/understands limitations/motivated/treatment fatigue
“understands/limited knowledge Tx” w/up including [CPET, TB/hep B/C etc at tertiary centre OR “barriers to Tx include’
Mx - Multiple tapered prednisolone courses/now pred dependent;
Inhaler w/ spacer requiring x times per day
pul rehab, vaccinations infl/pneumo, percussion, abx courses, long term, pall care, lung reduction/valves
Action plan, regular PEF testing
Heart failure/IHD
“Mr X was diagnosed with [type of failure] X years ago
If new dx then “after Sx for X months, presentation for Y”
If unclear cause identified AND not previously stated “Risk factors include etOH, IHD, valvular disease, prior pericardial effusions, chemo, myopathy FHx CCF”
“Current exercise tolerance is”, X pillow orthopnoea, PND; care needs several months” Current dry wt is.
“Multiple hospitalisations in past X months”
“His current EF is X%” OR it would be important to know results of recent TTE/stress MIBI etc. “QRS interval”
“Investigations include normal coronary angiogram X years ago, cardiac MRI etc.
“Managed by” [cardiology care team X times/year], FR/salt restriction, daily weight and action plan, ACEI/ARB, BBlocker, MRA, ivabradine, sacritrubil, frusemide
“He has an automated cardioverter defibrillator for [primary/secondary] prevention” (following an admission in X for presumed VT arrest) serviced 6 monthly
[age],[SESs], [cancer], [comorbids] are barriers to Tx” or “Her transplant work up includes”
CKD/AKI - initial hx
The factors [poorly controlled HTN, T2DM, crescentic GN, PCKD,] have contributed to a precipitous decline in his renal function over X years/months” OR
“he was diagnosed with X disease on renal Bx on [time] and subsequent [rapidly progressive GN/{precipitant} AKI]
“He reports current eGFR of X and urinary protein of X which is [declining/stable] over past X [time] despite a [X month]/[X cycles of cyclophosphamide/prednisolone, plasma exchange]
CKD/AKI - RRT
“After [precipitant to RRT - toxins, AKI, fluid overload, uraemic bleeding]
“and after failed PD following [recurrent peritonitis/diminishing dialytic efficiency”
“He had commenced HD via [permacath/ brachiocephalic/radiocephalic/AV graft] on Date and [drives/transported to his regular [TTS/MWF/daily noctural] [hour] dialysis, makes x mls urine”
OR
“He manages [continuous automated peritoneal dialysis/automated peritoneal dialysis] via a tencholff catheter [independently/with aid of X] and adheres/non adherent to strict hand hygiene”, “He receives support and regular dialysate bags from the X PD service.
He reports [good/challenging] adherence to a X litre FR, is currently on [diuretic and dose], reports [daily weights/regular weights] and has an action plan with a [stable/increasing] weight of X with dry wt of Y
“There has been no reports of inter-dialytic hypotension, seizures or other complications”, “Graft access has/not been complicated by [line sepsis/fistula stenosis]”
OR
“There has/not been reports of recurrent peritonitis”, “Constipation is is not a major concern and managed with X”
“Mr. X awaits renal transplant and completed a comprehensive medical and psychological work up including [HIV/Hep B/C] OR “Is awaiting work up” or “barriers to transplant include”
CKD complications
“Complications of ESRF in Mr X include:”
{High turnover/adynamic} metabolic bone disease OR [secondary hyperparathyroidism/tertiary hyperparathyroidism] noting raised phosphate PTH and [high/normal/low] calcium. She awaits/has undergone parathyroidectomy X years ago w/ parathyroid reimplantation in her X” OR “adynamic bone disease confirmed on Bx”
“She is adherent/non adherent to a low phosphate diet” on [phosphate binders] with meals and on calcitriol”, “She reports no fractures”
“Her renal anaemia is managed with [EPO] weekly/monthly, and receives regular iron infusions [presumably] during dialysis. She is/ is not aware of Hb or iron
“She reports intermittent hyperkalaemia [despite/contributed from non adherence] to a low potassium diet managed on the appropriate potassium bath
“She reports restless leg syndrome managed on X
“There is no history of uraemic haemorrhage/encephalopathy or uraemic dermopathy”
IHD/CVD active disease
Mr. X has been diagnosed with IHD/CAD after presenting with (non) ST elevation myocardial infarction X years prior OR recurrent presentations of NSTEMI/STEMI/myocardial infactions
“Risk factors include a family history of premature CAD, HTN, dyslipidaemia, smoking, T2DM, male”
“He has required multiple bare metal/drug eluting stents in X territories in [dates]” AND/OR “X coronary artery bypass graft using mammary/radial artery/saphenous venous harvest grafts”
“He currently reports an exercise tolerance of X limited by exertional angina/dyspnoea”, “EF of X”, unclear of recent echocardiogram in X
Medical therapy includes aspirin/clopidogrel/beta blocker/nitrates/statin
He has attended cardiopulmonary rehabilitation, adheres to a low salt, low fat high vegetable diet and up to date with pneumococcal and influenza vaccinations
“His most recent MI has been complicated by: new ventricular septal defect/ventricular aneurysm” “VT arrest requiring intensive care inotrope support and automated cardioverter defibrillator insertion”
IHD primary prevention
His coronary artery disease risk factors include
“well/poorly controlled HTN on meds, dyslipidaemia on statin, known TG/chol is, T2DM, smoking
“A recent stress MIBI following acute /chronic (troponin/ECG negative) ischaemia is normal/demonstrates”, “A recent CT angiogram/coronary angiogram demonstrates..”
“He reports no chest pain with exercise or at rest”
Cirrhosis
“In regards to her Child-Pugh ABC cirrhosis, she was diagnosed in X”
“Her risk factors include etOH, Hep B/C, haemochromatosis, Budd-Chiari, autoimmune hepatitis, cystic fibrosis, alpha1 antitrypsin”
“Confirmed on fibroscan/biopsy”, important to identify coags/LFT/alb/BR
“Disease progression over X time has resulted in (mild/severe) portal hypertension, “the components include oesophageal gastric varices, (refractory) ascites and (hepatorenal syndrome)
X varices were banded after recent endoscopy on [time; currently on bblocker”
“He has required urgent endoscopy, balloon tamponade and intensive care admissions for life threatening variceal haemorrhage on X occasions, with admissions further complicated by.. PSE/SBP
“He has had multiple hospitalisations with decompensated cirrhosis, with most recent likely precipitant of X..”, “He reports a normal intercurrent mental state, managed on lactulose, opening bowels TDS and on rifaxamin”, “he currently drives”
“Previous ascites have been controlled spironolactone/frusemide and adherence to a no-salt diet” OR refractory ascites despite diuretics and dietary advice requiring [weekly/monthly] therapeutic paraceteses (and intravenous albumin) draining (volume range)
“He has been treated for recurrent spontaneous bacterial peritonitis and currently on norfloxacin 400mg for prophylaxis”
“He is currently on terlipressin after declining renal function and awaits liver transplant following a work up including”
“Transplant has been discussed/on the wait list / barriers include..”
“There are plans/no plans for transjugular intrahepatic portal shunting, and potential difficulties include prior PSE
Metabolic syndrome/obesity
“I note the presence of probable metabolic syndrome given - abdominal obesity, HTN, T2DM and dyslipidaemia
“In terms of obesity, he currently weighs x kgs, has a history childhood obesity, has a maximal weight of x kg, weighs himself daily/weekly, has had previous successful/unsuccessful attempts to lose weight; would like to loose weight and struggles with – sat fats/portion size/high carbs
Has a largely sedentary lifestyle/participates in physical activity
Has involved a dietician/GP, has/has not considered bariatric surgery
Complications of obesity include fatty liver dx on USS and monitored by GP, OA of knee/hip, gout, OSA, with a moderate AHI on sleep study, controlled on CPAP, nil MVA
Inflammatory bowel disease - initial history
“Mr. X was diagnosed with [presumed] [stricturing/non stricturing] Crohn’s disease/ [pan-colonic/sigmoid predominant] ulcerative colitis/microscopic colitis in X
Risk factors include smoking, FHx of autoimmune disease
(After initally presenting with X weeks/months of frequent [hematochezia], watery bowel motions AND
{a history suspicious for inflammatory oligoarthritis, uveitis, erythema nodosum}
Colonoscopy confirmed [continuous/discontinuous] lesions of the [entire/sigmoid/ascending/descending colon; ileus] )
Currently has had[X] flares over [since diagnosis], progressing in severity [requiring [X] hospitalisations],
He is currently [in remission] for X months/years after commencement of prednisolone, azathioprine, mtx, cyclosporine, infliximab monthly, adalimumab]
OR
His recent relapse is characterised by [hematochezia/watery diarrhoea/abdominal pain/new cutaneous/anal fistulae] fatigue/malaise
He had not responded to aza, mtx, infliximab
He has required X multiple days sick leave/faecal incontinence causes significant social embarassment
He has required X tapering courses of prednsiolone, maximal dose of X, is not prednsiolone dependent/long term maintenance dose of Xmg
He his adherent to a low residue diet, is reviewed by a dietician
Toxic megacolon/colonic dysplasia prompted urgent colectomy, end-ileostomy creation and S/W pouch; He reports no pouchitis/faecal incontinence
He adheres to regular gastroenterology follow ups at an IBD centre, has regular contact with an IBD/stoma nurse and dietician and regular surveillence blood tests whilst on AZA/MTX/CYC
IBD complications - structural
His crohns/UC
is further complicated by [colon/small bowel/cutaneous/cystic/vaginal/rectal fistulae] managed with multiple surgical interventions and infliximab AND/OR rectal fistulae requiring seton placement
(with the added consequence of adhesive SBO requiring operative/non operative management)
X small bowel [inflammatory]/non inflammatory strictures responding to immunosuppressive/requiring surgical intervention
He has/has not developed recurrent rectal/abdominal abscesses; requiring surgical drainage
IBD complications - infectious/inflammatory/metabolic/nutritional
There is no history of CMV/c. diff colitis; recurrent/single episode treated with IV valganciclovir OR oral vancomycin for 6/52
he reports [intercurrent/concurrent] oligoarthritis and sacroilitis involving the [joints] w/ associated uveitis that have responded to immunosuppressive therapy
Despite remission, he reports non inflammatory/bile acid diarrhoea, with daily frequency of X. managed with cholestyramine w/ modest/significant benefit
After an cumulative total small bowel resection of X metres, he has developed short gut syndrome; well managed on a high carbohydrate, medium chain triglyceride, fibre diet with regular day unit intravenous fluids and electrolytes
He undergoes yearly colonoscopies without evidence of colonic dysplasia to date
He reports no rashes suggestive of eythema nodosum or gangrenosum
He reports no renal calculi or DVT
Prednisolone complications
Mr X has had multiple complications from prednisolone including obesity, HTN, dyslipidaemia, cataracts and hyperglycaemia, all developing after long term prednisolone use OR “likely to have posed management challenges to pre-existing HTN, dyslipidaemia and T2DM”;
Other complications included osteoporosis/avascular necrosis of hip, confirmed on DEXA scan OR presumed [vertebral/femoral/ulnar etc] fragility fractures/fragility fractures previously required IV zoledronic acid/alendronate/densumab/antiresportive therapy
Additionally, prednisolone/steroid related myopathy, impairing mobility and transfers
He reports steroid induced psychosis requiring inpatient psychiatric involvement OR sleep impairment
He reports of increased infections including candida/thrush
Gastroesophageal reflux well controlled with esomeprazole
Falls
Intrinsic factors - His [diabetic neuropathy], [poor vision], [dyspnoea] [postural dizziness], [parkinson’s disease, stroke deficit], [frailty], [etOH], [RA} increase his risk of falls
Extrinsic factors - Additionally, he is home alone, wears slippers, has a small cluttered house, stairs/steps, rugs
Has had OT home assessment, rails, shower chairs, bathmats
He has had multiple falls over past 6-12 months, complicated by … fractures/injuries, head injury, hospitalisations
He uses a 4WF, SPS although reports variable compliance
Tacrolimus/cyclosporin complications
He reports no tremor, gum hypertrophy or post transplant T2DM or HTN, or renal impairment or electrolyte disturbance OR “tacrolimus has posed challenges to glycaemic and hypertensive control”
His tacrolimus levels have been stable on periodic review
He reports posterior reversible leukoencephalopathy syndrome characterised by generalised tonic clonic seizures attributable to cyclosporin/tacrolimus
Geriatric assessment
Multiple falls, with extrinsic and intrinsic risk factors (above), use of a 4WF
Urge/stress/mixed incontinence and nocturia, requiring the use of continence pads/pessaries/anticholinergic medications
Complaints of memory issues, with an AMST of x/10
Given multiple comorbidities, and assistance with some/all pADLs and dADLs I would estimate a Rockwood frailty score of x indicating vulnernability, mild/moderate or severe frailty
Glasses/bifocals for reading
Hearing aids for presbyacusis
Social history script
Mr. X previously worked as … after finishing school at year… or completing a university degree
He currently lives with his wife/partner, son/daughter and reports a [stable/tenuous/abusive/unsupportive] relationship
He has a young family and x children under the age of …
He is currently working/recently ceased working due to ill health for several months
He is currently supported on disability insurance/disability support and partner’s/son/daughter’s salary
Medication and specialist appointment costs are an issue
Lives in a single storey/double storey house with 1-2 steps, has had previous bathroom modifications
He is currently independent with ADLs
Requires assistance with showering, dressing, using cutlery, and assisted by carer/physical adjuncts
He currently requires SPS/4WF /independently mobilising
Currently drives/does not drive
Takes public transport to get to appointments
Has pets
Enjoys community activities, involved in, hobbies
Health is impacting on this recently, and noted to feel isolated
His biggest concern is – his pain, wife’s care needs, prognosis
Insight – he sees himself symptom free/back at home which is realistic/unrealistic
Meds/General health 13
“Current medications unaccounted for include x which is possible indicated for [disease discussed]
“Possible drug interactions include {drugs]
“She takes medications from boxes/packaged pharmacy/fills her own pillbox weekly
“Reports good adherence/variable adherence, takes medications in morning and night with/without meals
“Has allergies/intolerances to … or anaphylaxis to penicillin etc
“He reports a good relationship with a regular GP
“Is up to date with influenza, pneumococcal and varicella vaccinations
“Has participated in the national bowel screening program 2 yearly; up to date with 5 yrly cervical and biennial mammograms (50-74)
“does/not participate in regular exercise, has a balanced/high sat fat diet
“Has no vegetative symptoms of depression or anxiety
“Lifelong/distant non smoker and non drinker
“Barriers to care include transport/access, poor health literacy etc.
“Has an advanced care directive and will in place
Mental health
“I note during the interview that Mr. X admitted to sadness/guilt loss of interest in activities and poor sleep, for X weeks suggestive of depression. Suicidal/no suicidal ideation is noted
“I note increased worry, guilt, clouding of thoughts, anxiety attacks suggestive of an anxiety disorder
Contributing factors include – ongoing pain, social isolation, ongoing etOH use, family stressors, financial status, death of loved ones, unwell family member, loss of independence/drivers licence, faecal/urinary incontinence, previous history of depression
Protective factors include – supportive family and GP, resilient personality, physical exercise
This is currently managed/not managed by GP/psychologist/psychiatrist and currently on [antidepressant]
“I note a well-controlled history of Scz, bipolar disorder on [medication], reviewed by psychiatrist”
Osteoporosis
Mr. X’s risk factors for osteoporosis include alcohol, smoking, prednisolone, IBD, hyperthyroidism, hyperparathyroidism, coeliac disease, IBD, multiple myeloma
Mr. X’s last DEXA was 2 years ago, with a T score of …
He has had humeral/femoral/vertebral/radial/ulnar fragility fracture/no fracture
Currently managed with bisphosphonate/denosumab/antiresorptive therapy/vit D/calcium
Participates in regular weight bearing exercises
No history of prior dental extraction
Vasculitis -initial Hx
Mr X. was diagnosed with [small vessel/medium vessel/large vessel] or type vasculitis after presenting with x months of [symptom] in [year]
Risk factors include family history, known RA, SLE
Prodromal events include [progressive treatment resistent asthma/atopy for X years; recurrent rhinosinusitis/haemoptysis/haematuria (wegners); headache/visual disturbance; non blanching purpura;]
in addition to [malaise, fatigue, sweats, loss of weight/appetite]
Diagnosis was confirmed on [renal/skin/bronchoscopic Bx] after hospitalisation for [haemoptysis/progressive AKI/headache]
He is unaware of Anti-neutrophil cytosolic antibody studies
He has multiple internal organ vasculitic manifestations including [crescentic/rapidly progressive GN], leucocytoclastic vasculitis, haemorrhagic alveolitis, granulomatous sinusitis, ascending sensory polyneuropathy, eosinophilic asthma, coronary vasculitis/myopericarditis
His team achieved remission after completing X cycles of intravenous cyclophosphamide therapy; after a tapering course of prednisolone
“He is up to date with vaccinations, is reviewed by [specialist regularly] and reports no drug related complications with regular LFT and FBE monitoring
He is aware that his multiple organ manifestations portend a poor prognosis and risk of relapse
Rapidly progressive GN (vasculitis)
His most significant complication is [rapidly progressive] glomerulonephritis, with a current eGFR of X noting a precipitous decline from [initial] in several months; currently making X mls urine; previously required acute haemofiltration via [vascath] X months ago
He awaits arteriovenous mapping studies for AV fistula in anticipation for HD or he awaits Tencholf catheter insertion; he has received HD/PD dialysis education
He awaits transplant work up/barriers to transplant include/Hep BC/HIV/TB screening is negative/he is currently on waitlist
He has undergoing X cycles of intravenous cyclophosphamide/mycophenolate (SLE) therapy; after a tapering course of prednisolone OR he has not responded to a 6 month course of high dose cyclophosphamide
He is currently on second daily trimethoprim-sulphmethoxazole for pneumocystic jeroveci prophylaxis
He has commenced steroid sparing AZA/MTX for X months, with no BM/hepatotoxicity on routine liver function tests and full blood count test
Vasculitis - other manifestations
Cutaneous manifestations include (refractory) (painful) [leukocytoclastic vasculitis/urticarial vasculitis] involving arms/legs/torso, confirmed on skin Bx/manifesting with henoch-Schonlein purpura; currently on a tapering course of prednisolone after commencing MTX/AZA
Neurological manifestations include peripheral [sensory/motor] polyneuropathy/mononeuritis multiplex involving [CN, arms/legs] confirmed on NCS on X date; impairing walking now requiring 4WF, difficulty with pADLs
Gastrointestinal complications include (stable/refractory) vasculitic (entero)colitis confirmed on colonoscopy and Bx; after a previous bout of severe haematochezia with stable remission following high dose prednisolone and AZA
Pulmonary complications include haemorrhagic alveolitis after presenting with large volume haemoptysis confirmed on CT and bronchoscopy; requiring radiologically guided embolisation/bronchoscopic cautery
Complications of cyclophosphamide
He reports no haemorrhagic cystitis, recurrent viral/bacterial infections whilst on therapy; he notes alopecia and recurrent mucositis which have/have not been a significant concern
He is aware of potential gonadotoxicity and after family fertility clinic review has participated in sperm banking
Scleroderma - Hx
In regards to her [diffuse/limited] [scleroderma/systemic sclerosis] she initially presented with progressive skin changes/raynauds as early as X years ago
Her risk factors include a family history, previous GVHD, polyvinyl exposure
Her cardinal manifestation includes progressive sclerodacyly involving her hands arms and mouth, worsening over past 2 years; flexion contractures limit fine finger movement, and is now dependent on her carer for pADLs including assistance with cutlery
Her raynauds vasculopathy manifests in hands bilaterally, is exacerbated by cold weather and has resulted in multiple painful ulcers; her pain is modestly relieved with opioids GTN patches, and intravenous iloprost; and has failed calcium channel blockers
Her left index and right ring finger arterial ulcerations have been complicated by soft tissue infection and osteomyelitis, requiring partial amputation
Other manifestations include bilateral carpal, knee and feet calcinosis which results in significant pain; this is confirmed on X ray findings; no joint deformities have developed; previously managed with surgical resection
Scleroderma - internal organ manifestation
Gastrointestinal manifestations include oesophageal dysmotility, gastro-esophageal reflux, gastric antral vascular ectasia, small bowel overgrowth, rectal dysmotility etc.
Her oesophageal dysmotility is [long standing], confirmed on [oesophageal manometry] causes clinically significant odynophagia and dysphagia which limits oral intake. She manages 5 dietician formulated small liquid meals a day; she has sustained weight loss of X despite this; and awaits percutaneous endoscopic gastrotomy tube to assist nutritional goals; she has a modest response to domperidone TDS
Gastroesophageal reflux occurs independently of meals and is exacerbated when supine; oesopheal pH testing confirms this; it is refractory to esomeprazole, nizatidine; an incline bed assists with symptoms; she has not been considered a candidate for Nissen fundiplication
“There is no evidence of pulmonary hypertension, percardial or interstitial lung disease with annual echocardiograms and CT chest surveillence
“There has been no renal manifestations and hypertension is controlled with ramipril
SLE- initial history
Mrs. X was diagnosed with [mucocutaneous] systemic lupus erythematosis [with renal/cardiopulmonary/multiorgan involvment] in X or [time]
Her risk factors include family history autoimmune disease, recent OTC medications
Initially she presented with malar rash/discoid rash/mucocutaneous ulcers with associated systemic symptoms for X months OR 3 months of haematuria and progressive acute renal failure OR other syndrome
It has progressed to multiorgan involvement including lupus nephritis, pericarditis, pleuritis, thrombocytopaenias etc.
Her ANA/dsDNA/Anti-Sm/Anti-Ro/La antibody status is unclear to her
Her most cardinal feature is that of…
Other internal organ manifestations include possible peripheral sensory neuropathy; describing
Cutaenous manifestations include..
She describes recurrent non provoked PE and DVT within 4 years; now warfarin; INR checked fornightly, nil history of haemorrhage or etOH; not clear of antiphopholipid status; nil history of miscarriages.
Nil complications during pregnancy; describes previous depression without significant SI or hospitalisation; a previous MRI-B was normal; currently managed on mirtazapine
Her most salient issue is that of progressive discoid lupus, resulting in dysmorphic changes to her scalp and scarring alopecia; this has caused social embarassment that has contributed to her depression; she wears custom fitted hair pieces and has a supportive partner.
Lupus nephritis
Her most cardinal feature stage X lupus nephritis diagnosed X years prior.
Her current eGFR is X from a precipitous decline of X [time] ago. She currently makes X mLs urine, has a protein Cr. ratio of X, and currently haematuric.
Her disease currently in remission/stable after 2 weekly IV cyclophosphamide/mycophenolate for 6 months and induction corticosteroid therapy. She is currently on maintenance mycophenolate
OR
Her disease is unresponsive/refractory to cyclophosphamide and awaits PD/HD/Tx; she has undergone vascular mapping/AVF formation/tencholf insertion; her infective and neoplastic pre-transplant screening was negative and currently on the waitlist
She is currently on ramipril for management of proteinuria; additionally spironolactone and amplodipine for HTN
Trimethoprim/sulphamoxazole for pneumocystic jiroveci prophylaxis whilst on high dose prednisolone
T2DM -initial history
Mr. X has T2DM [with microvascular end organ damage] diagnosed X years ago following routine GP screening/after a period of impaired fasting/post prandial glucose
Risk factors include FHx, obesity, gestational DM, Aboriginal/Islander/SE asain descent, chronic steroid/antipsychotic use
After several years of suboptimal/optimal glycaemic control, his HbA1c is X and been stable/improving/worsening over X
His blood glucose is tested X times a day/week before [meal] and reports a range of X
His glyceaemic control has been previously been refractory to [dietary/lifestyle, metformin/gliclazide alone/combination] and now on [premixed/basal bolus insulin]
He is reviewed x monthly by an endocrinologist, diabetic educator, podiatrist, ophalmologist accessed through the National Diabetes Services Scheme arranged by his GP
He currently has a conditional licence
T1DM
Mrs. X was diagnosed with T1DM since childhood/late in life
Risk factors include FHx, PHx Coeliac, hashimoto’s, Addison’s, pernicious anaemia
Her HbA1c is X and currently stable for several years/improving following a period of poor control for X years/unclear of HbA1c
BGLs range between X and tested before meals, reviewed on phone with CGM
She has had X admissions to hospital with DKA with precipitants including X; this is in spite of a detailed sick day plan
She is reviewed by endocrinologist 6 monthly
Diabetes - insulin history
He currently is on [basal insulin] X units/day with bolus insuln X units or premixed insulin or insulin pump
He tests his blood glucose before meals, reports BSL at X
OR has continuous glucose monitoring/pump, replaces needles X weekly; has a working battery, and recently upgraded
He adjusts his insulin after carbohydrate counting, has an insulin sensitivity factor of X; has a sliding scale
He rotates his insulin sites regularly and stores insulin in fridge
He checks insulin before driving and exercise
He has an insulin sick day plan and hypoglycaemic plan
Reports infrequent/regular symptomatic hypoglycaemic episodes with a BSL of X, has not lost consciousness or required hospitalisation
Microvascular complications DM
Mr. X reports no micro or macrovascular complications of DM or recurrent infections, is reviewed by ophalmologist 12 monthly, podiatrist 6 monthly, and urinary albumin tested by GP 6 monthly OR
He has multiple microvascular end stage manifestations of DM including
Painful/painless peripheral neuropathy [with femoral/popliteal PVD refractory to angioplasty/stenting/bypass] with[charcot] manifesting progressive left diabetic foot]
with multiple neuropathic ulcers of feet, requiring multiple hospitalisation for treatment of [polymicrobial/pseudomonas] foot infections; further complicated by digital amputations for treatment of [OM] or gangrene in X
Proliferative/non proliferative retinopathy [requiring/refractory to] photocoagulation x3 therapy, ezetimbe; he reports optimal/suboptimal vision
Progressive diabetic nephropathy with an eGFR of X and micro/macroalbuminaemia making X mLs urine; reviewed by a renal physician; awaiting Tx work up/access creation for HD/PD
Severe gastroparesis managed with domperidone/erythromycin/awaiting gastric pacemaker
Postural hypotension managed with fludrocortisone therapy, detrusor dysfunction complicated by recurrent UTIs and incontinence managed with catheterisation
Recurrent genitourinary candidal infections
Macrovascular complications DM
Macrovascular complicatons include:
IHD after multiple NSTEMIs/STEMIs with known LAD/RCA/LCx requiring multiple BMS/DESs on recent angiogram OR on stress MIBI AND/OR X vessel coronary artery bypass grafts with additional risk factors including HTN, dyslipidaemia; smoking; Currently managed on aspirin, atorvastatin, HCT, ramipril
Currently reports no chest pain/ET of X metres
L) middle cerebral artery ischaemic infarct in X, requiring thrombolysis [confirmed on MRIB) with R) residual paresis/nil residual deficit; known L/R carotid disease on previous CT-BA requiring endarterectomy currently on aspirin/clopidogrel
Peripheral vascular disease of the L)/R) iliac/femoral/pop artery further excerbating existing diabetic foot complications; requiring fem-pop bypass on X/BM stenting of the artery; does not report claudication
Further complicated by aortic disease with a Xcm aneurysm on recent USS; with ongoing surveillence by vascular surgeon with no plans for intervention at this stage
Obesity
Mr. X is [centripetal] [obese/morbidly obese] with BMI of X with additional features of metabolic syndrome HTN/dyslipidaemia
Risk factors include FHx, steroid/antipsychotics, hypothyroidism/Acromegaly
He reports childhood obesity/excessive weight gain during X, has a maximal weight of X
Weighs himself daily/weekly; eats x meals per day of large/small size typically homecooked/takeout; He acknowledges the biggest food barrier to weight loss is X; he participates in regular exercise consisting of/no exercise
He has attempted calorie controlled diet with modest/great success w/ dietician imput; Attempted VLCD with GP; medical weight loss adjuncts include GLP-1 weekly; on waitlist for gastric bypass/not yet eligible for gastric bypass
Complications of obesity
Complications of obesity include
- Obstructive sleep apnoea dx on sleep study X years prior with an AHI index of X; reports no daytime sleepiness/significant fatigue with an Epworth sleepiness scale of X/due to CPAP adherence/non adherence; has no issues with mask fitting; is unable to afford device; has been serviced recently on; drives with a conditional licence
- Obesity hyperventilation confirmed arterial blood gas after progressive dyspnoea and fatigue; does not recall CT chest or echocardiogram findings; is on home O2 at X L/hr
- steatosis/steatohepatitis suggested by deranged LFTs and USS and confirmed on Bx; Risk factors include T2DM; there is no history of oesophageal varices, ascites, hospitalisations for decompensated cirrhosis;
Atrial fibrillation/arrythymia
He has paroxsymal/persistent/permanent atrial fibrillation [secondary to WPW] with CHADS2Vasc of X; initially diagnosed on ECG during a hospital admission
Risk factors include obesity, COPD, HTN, CCF, thyroid disease
He describes intermittent palpitations/his AF is asymptomatic; has had recent syncopal episodes requiring admission
He has required multiple hospitalisations with RVR being apparent and complicated by CCF
His AF has been refractory/controlled with DC cardioversion on several occasions
He has previously had successful/refractory to ablation OR awaiting electrophysiological studies and ablation
He has had an automated cardioverter-defibrillator inserted as primary prophylaxis/following a presentation of VT arrest
Has had a permanent pacemaker following ablation after symptomatic bradycardia and/or recurrent falls; this is interrogated annually and there are no current lead or device issues
He is currently managed on betablocker;amiodarone; digoxin; reports no respiratory or hepatic complications of amiodarone
He is anticoagulated with apixaban, dabigatran, rivaroxaban, warfarin; reports no previous haemorrhage or current malaena; INR is tested X times month and stable; minimal etOH
There is no history of thyroid disease, significant etOH or chronic electrolyte disturbance
Valvular disease
Mr X has mitral stenosis/mitral regurgitation/aortic stenosis diagnosed following recurrent presentations with heart failure/noted after review by GP
Risk factors include childhood history of rheumatic fever, Marfan’s, IHD, carcinoid,
He reports prior [methocillin resistant staphylococcus] infective endocarditis requiring multiple courses of intravenous antibiotics and recurrent valve replacements w/ bioprosthetic/metal valves
TTE demonstrates reduced EF with significant stenosis/regurgitation
He is currently managed on beta blocker; warfarin
He awaits valve replacement/no longer a candidate for valve replacement
