Discussion and Personal Reactions:
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- Bernadette Rice
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1 INSTRUCTIONS FOR THE PRECEPTOR Please assign the students a patient to meet and interview, there can be 3-4 students/patient not necessarily 1:1 Patient should preferably be living with advanced illness rather than end of life ie hours to days. The students should be given access to the medical record to note such information as medications, labs, radiology, date of birth, etc The students should present the case and then discuss with preceptor findings Special stress on role of palliative care in management of advanced illness and their evaluation of patient s, family s and their own response to the care Discussion and Personal Reactions: - Identification of patient's overall reaction to chronic illness and goals for treatment and management of illness. - Gaps between patient goals and medical context caused by: - Providers role in making medical care congruent with patient/family goals and values. - Need for Palliative care involvement - Barriers to appropriate care. - Significance of the case to your overall preparation as a physician.
2 Palliative Care Experience Please complete with your faculty preceptor the information below. Please return this cover page, completed, to Adriana Nieto by or in person (Block 423). Student Name IN PRINT Student Signature Site Faculty Signature Date of Attendance
3 PATIENT INFORMATION Age: DOB: SOURCE OF INFORMATION: Patient/Family Member / Medical Records WAS THE PATIENT RELIABLE: Yes / No due to TRANSLATOR USED: Yes/No CHIEF COMPLAINT: (What bothers you the most?) HPI: (history of onset and course of disease related to functional abilities.) REVIEW OF SYSTEMS 0=None Depressed Mood Anxiety Insomnia Fatigue Weight loss Decreased Appetite Shortness of breath Confusion Pain Constipation Nausea/Vomiting Other U= Unknown 1+Mild 2=Moderate 3=Severe
4 ASSESSMENT OF FUNCTION (based on ADLS/IADLS and Palliative Performance Score) ADLS/IADLS Activities of Daily Living Indepen Needs dent Help Bathing Dressing Toileting Walking Eating Depen dent Unable To do Instrumental Activities of Daily Living Indepe Needs Depen ndent Help dent Shopping Cooking Managing Medications Using the phone Housework Laundry Driving/Trans portation Finances Unable To do PAST MEDICAL/SURGICAL HISTORY: Prior Hospitalizations (Emphasis on last 3-6 months): CANCER CAD/CHF COPD CVA DEMENTIA CKD HIV/AIDS PSYCHIATRIC OTHER: OTHER PSYCHO-SOCIAL HISTORY: (Including Limitations or conditions on expenditures, resources needed for treatment and life expenses, unmet needs)
5 FAMILY HISTORY PATIENT AND/OR FAMILY VIEW OF CHRONIC ILLNESS: (Information gained from interview of patient and family and/or significant others) Values and goals. What values and goals are shared by pt/family? What values and goals differ among pt/family? View of quality of life. What views of quality of life are shared by the pt/family? What views of quality of life differ among pt/family? For those patients/families living with advanced, life limiting illness was a palliative care discussion conducted? If so what were the pt/family values and goals for medical care? If not, why not? If not what was the effect on the pt/family medical care and quality of life? View of unmet needs for treatment or services. MEDICATIONS (Include Indications)
6 Allergies: Physical Examination: Vitals: BP: T: Pulse: Resp: Pain Score: Exam: Eyes: ENT: Chest: Cardiovascular Pulmonary: GI/Abdomen: GU: Extremities; Skin: Neurologic: Psychiatric: Laboratory/Radiology Results (only note those that are significant) Assessment and Plan (Based on 4 domains of Palliative Care) -Physical -Psychological
7 -Social -Spiritual Discussion and Personal Reactions: - Identification of patient's overall reaction to chronic illness and goals for treatment and management of illness. - Gaps between patient goals and medical context caused by: - Providers role in making medical care congruent with patient/family goals and values. - Need for Palliative care involvement - Barriers to appropriate care. - Significance of the case to your overall preparation as a physician.
8
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Page1 Mala Bathija MD, PLLC 44000 West 12 Mile Road, Suite 212 Novi, MI 48377 14500 Northline Road Southgate,MI 48195 NEW PATIENT QUESTIONNAIRE Last Name First Name Phone # DOB Age Sex: M F Referring Physician
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Let Us Know More - So We Can Help Thank you for choosing to schedule an integrative medicine consultation with UC Health. To help us meet your needs during your visit, please take some time to sit in a
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