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
