GENERAL ROTATION INFORMATION Wellness Clinic (Mon

GENERAL ROTATION INFORMATION

Wellness Clinic (Mon AM): Run by Dr. Kunkel. In bldg. 208 which is to the north of bldg. 158 where our Thursday didactics are. Walk up the stairs and straight and towards the left there is a blue fire escape. Go up one flight and you will see the waiting room. Mainly you see patients who have requested or have been referred to be able to use the exercise machines and whatnot. Screen for cardiovascular risk and refer for exercise tolerance test usually, prior to starting a tailored exercise program.

General PM&RS and Chronic Pain clinic: In room 1415 which is across from the didactics room. There are lots of residents and medical students, so you grab whatever chart is free and see patients. The attendings room is the one immediately on the left as you enter through the back entrance of the clinic. They can give you an overview of what to do and how to use the CPRS templates.

Morning didactics (Daily 8-9am) 1st floor classroom 1277 (walk straight through the hospital and it will be on the left side Tuesday didactics (Tues 2-5pm): In basement Simulation Center Lecture auditorium or 1st floor classroom 1277

Wheelchair Clinic (Wed PM): Run by Dr. Darvish. It's in building 304 as well. Instead of going down the long hallway on your left, you go right and immediately into the large room with equipment and gait cameras on the walls (which supposedly aren't working right now?). It's an interdisciplinary team with PT, wheelchair techs, PM&R resident who does all the charting, and attending. Good way to learn about various wheelchairs, medical indications for wheelchairs. You mainly observe/listen, since the PM&R resident charts. You can help out and talk to the patient, but PT and attending usually lead the clinic.

Cardiac Rehab Clinic (Fri AM): Run by Dr. Aragaki. Clinic is in Room 1612, you can see the “Cardiology Clinic” sign if you walk straight into the hospital. There are these good handouts that Dr. Aragaki has to explain the background of cardiac/pulm rehab, rehab for people with cancer. There are some good UpToDate articles on cardiac rehabilitation as well. Template is below. Similar to Wellness Clinic where you screen people for cardiovascular issues +/- exercise tolerance test, Cardiac Rehab clinic enrolls patients in rehab (different "phases" which involve different modalities).

CODES The code for the injection supply closet in the general PMR clinic is 1532. Resident room is room 1278 (right next to room 1277). Door code is 4315. You may store lunch and small personal items. Code for clinic room 1415 is 24351 There's 2 chief residents who have been welcoming/helpful. Chiefs for 2017-18 are Sunny Sharma ([email protected]) and Ian Dworkin ([email protected]).

CARDIAC REHAB CLINIC

CC/reason for consult:

HPI:

ROS: Denies chest pain, SOB, palpitations, DOE, orthopnea, PND, edema, light-headedness, syncope.

PMH: |ACTIVE PROB LIST-SHORT|

SH:

FH:

Functional Hx:

All:|ALLERGIES/ADR|

Meds: Provided and reviewed printed medlist with veteran. reports compliance. |ACTIVE OUTPATIENT MEDICATIONS|

PE: Vitals |TEMPERATURE| |BLOOD PRESSURE| |PULSE| |RESPIRATION| Gen: WD, NAD, pleasant and cooperative Gait: HEENT: NCAT, EOMI, anicteric sclera, OP clear Neck: no JVD, FROM, supple and nontender CV: RRR, nl S1 and S2 Chest wall: Lungs: CTA B, no crackles/wheeze/rhonchi Abd: soft, nt, nd, +bs Ext: no pedal edema. intact distal pulses Musculoskeletal: ROM within functional limits all major joints Neuro: Speech fluent. Alert and appropriate Sensory: intact to LT all ext Motor: 5/5 throughout with no focal muscle atrophy fine motor coordination intact No Clonus normal Tone

Imaging:

Echo:

Cardiac Cath:

ETT/Thallium stress test:

Labs: reviewed

A/P:

- Ordered ETT to assess functional capacity and clear for phase II program

- Will create Phase II Cardiac Rehab exercise prescription based upon ETT performance and enroll in program for nutrition counseling, psychosocial support groups, smoking cessation, stress reduction, cardiopulmonary education and monitored aerobic exercise. 3x/week for 2 hour morning session for 6 weeks.

- continue current meds per PMD and cardiology

- Preventive Health: Education provided regarding health conditions and treatment options. Encouraged smoking cessation. Discussed importance of weight management through healthy diet choices, portions, and exercise. Reviewed fall prevention strategies.

- d/c from clinic.

- Educated patient regarding self-directed, symptom-limited exercise program with goal to walk 20-30 minutes 5x/week on level ground in safe environment with appropriate assistive device as needed.

MEDICATION ASSESSMENT: Current medications were reviewed with patient ACTIONS: No changes made to current medication list Provided and reviewed printed medlist with veteran. reports compliance.

- pt reported understanding and agreement to plan above

(only if already cleared by ETT) - will cc exercise physiologist, Amanda Phillips, PhD to help coordinate orientation and enrollment in Phase II cardiopulmonary rehab program.

Weeks: Target Heart Rate (bpm) 0-2 (40%) 3-4 (50%) 5-6 (60%) Precautions: hold for BP> hold for any concerning cardipulmonary symptoms. polar monitor. Seated machines preferred given fall risk.

(if pt declines formal phase II program) - educated patient regarding self-directed, symptom-limited exercise program with goal to walk 20-30 minutes 5x/week on level ground in safe environment with appropriate assistive device as needed.

GENERAL REHAB CLINIC CC/Reason for referral:

HPI:

ROS: No fever/chills, undesired appetite/weight change, SOB, cough, palpitations, CP, constipation/diarrhea, bowel/bladder changes, or focal numbness/weakness.

PMH: |ACTIVE PROB LIST-SHORT|

All: |ALLERGIES/ADR|

Meds: |ACTIVE OUTPATIENT MEDICATIONS|

SH: Tobacco Etoh IVDA

Functional Hx: Independent with all ADL's.

PE: Vitals: |TEMPERATURE| |BLOOD PRESSURE| |PULSE| |RESPIRATION| |PATIENT WEIGHT| Gen: WD, NAD Gait: CV: Lungs: Abd: Musculoskeletal: Neck: Inspection - Palpation - ROM - Spurling's Trigger points/palpable taut bands Back: Inspection - Palpation - ROM - SLR Thomas test Ober's test Fabere's test Pelvis: Inspection - ROM - (L) ER/IR (R) ER/IR Load and grind Nontender Greater trochanters, ASIS, SI ligaments, ischial tuberosities Knees: Inspection - erythema, edema, effusion Palpation - heat, joint line tenderness ROM - Valgus/Varus laxity McMurray's Anterior/Posterior drawer test Lachman's test Shoulders: Inspection - Palpation - ROM - Hawkin's, Neer's Empty Can sign Resisted ER/IR Subscapular lift Yergasin's, O'brien's Cross adduction Sulcus sign/ Apprehension-relocation sign Neuro: Mental status - CN II-XII - Motor: Delt Bic Tri WE WF FF Inteross HF Quad Hams TA EHL GS R L Atrophy Sensory: DTR's: Bic Tri Brachio Patella Achilles Babinski Hoffman's R L Clonus Tone Cerebellar - repetitive motions, finger-to-nose, heel-on-shin Romberg Gait

Imaging:

Labs:

A/P:

- Therapy

- Prosthetics

- Imaging/Referrals:

- Education

- Preventive Health: Discussed importance of weight management through healthy diet choices, portions, and exercise. Encouraged smoking cessation. Reviewed fall prevention strategies. FEDS = falls, exercise, diet, and smoking

- F/U

- Medications: - NSAIDS: Pt counseled regarding indications for use and possible side effects including renal insufficiency and GI upset/bleeding. Pt is advised to discontinue use and report to a physician if any adverse effects noted. - Gabapentin. Pt is to start at 300 mg qhs x 3 days. Then increase to 300mg bid x 3 days. If tolerated well, increase to 300mg po tid. Pt advised regarding clinical indications for use and possible side effects of drowsiness, nausea, confusion, and increased seizure risk if dose abruptly discontinued. Pt aware to report any adverse effects to physician.

- Pt expressed understanding and agreement to plan.

MEDICATION ASSESSMENT: Current medications were reviewed with patient/caregiver

ACTIONS: No changes made to current medication list OR The following medication changes were made:

FALLS CLINIC

Referral Physician/Source: Reason for Consult:

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CHIEF CONCERN: ""

HISTORY OF PRESENT ILLNESS

Date of last fall: Number of falls in past 3 months: 0 Assistive devices being used at time of fall: Injuries due to fall(s):

Fall-Focused review of systems: [ ] Recent weight loss [ ] Pain [ ] Vertigo with turning in bed [ ] Frequent urination or nocturia [ ] Sleep disorder [ ] Sedating medications: [ ] Fear of Falling: [ ] Other:

MEDICATIONS

PAST MEDICAL HISTORY (if non-fall-related, contextually relevant diagnosis; otherwise leave blank)

HEALTH MAINTENANCE (physical activity habits, last eye and hearing evaluations, ...)

SOCIAL HISTORY (people, physical home environment, along with tobacco, EtOH, other drug use, ...)

FUNCTIONAL HISTORY (basic, intermediate, and advanced activities of daily living (ADLs), ...)

REVIEW OF SYSTEMS

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PERTINENT PHYSICAL EXAM Pulse: 0 General and Other (i.e. skin and other as pertinent):

NEUROLOGICAL COGNITION MINI-MENTAL STATE EXAM (MMSE): 0/30 0/5 Orientation (day of week, date, month, year, season) 0/5 Orientation (floor, hospital, town, county, state) 0/3 Registration - 3 objects 0/5 Attention & calculation (serial 7's or DLROW) 0/3 Recall (3 objects) 0/8 Language (name 2 objects, "no if's and's or but's", 3-step command, read/obey sentence, write sentence: 0/1 Visual/Spatial (copy pentagon)

MINI-COG: 0/5 0/3 Recall (3 objects) 0/2 Clock drawing

VISUAL FIELDS:

VESTIBULAR SYSTEM Head shake:

SENSORY Proprioception: Light touch/pin prick:

COORDINATION Finger to nose:

STRENGTH UPPER EXTREMITY RIGHT LEFT /5 Shoulder abduction /5 /5 Elbow flex/extension /5 /5 Wrist extension /5 /5 Finger abduction /5 /5 Finger grip /5

LOWER EXTREMITY RIGHT LEFT /5 Hip flexion /5 /5 Knee flexion /5 /5 Knee extension /5

REFLEXES RIGHT LEFT /4 Biceps /4 /4 Brachioradialis /4 /4 Triceps /4 /4 Patellar /4 /4 Achilles /4 /4 Babinski /4 /4 Hoffman's /4

MOTOR TONE Clonus: Cogwheeling: Other:

MUSCULOSKELETAL Ankle range of motion: Foot deformities: Foot skin hygiene: Other:

STRENGTH Ten toe raises [ ] Yes [ ] No Sit to stand no arms [ ] Yes [ ] No

BALANCE: REFLEXIVE BALANCE Romberg: Shove test: VOLUNTARY BALANCE Lateral weight shift slow: Anterior/posterior weight shift:

OBSERVATIONAL GAIT DEVIATIONS [ ] Antalgic [ ] Steppage [ ] Ataxic [ ] Trunk forward flexion [ ] Decreased speed [ ] Vaulting [ ] Festinating [ ] Wide base of support [ ] Hip circumduction Trunk lateral lean [ ]R [ ]L [ ] Hip hiking Trendelenberg [ ]R [ ]L [ ] Scissoring Knee hyperextension [ ]R [ ]L [ ] Shuffling Foot drop [ ]R [ ]L [ ] None

PERTINENT LABS

******************************************************************************* *************************** ASSESSMENT/PLANS ************************** Based on Siebens Domain Management Model (SDMM) - see below for 4 domain headings; each problem identified along with its plan in corresponding domain.

FALL RISK FACTORS (relative risk) FALL INJURY RISK FACTORS

[ ] Age>80 (1.7) [ ] Female (1.9)

I. [ ] Muscle weakness (4.4)* [ ] Thin, BMI<22 (2.2) [ ] Arthritis (2.4) [ ] Peripheral neuropathy (2.5) [ ] Use of digoxin, diuretics, antiarrythmics (1.6)* [ ] >2 chronic conditions

II. [ ] Cognitive deficits, MMSE<26* [ ] Poor vision (2.4) [ ] Depression (2.0) [ ] Severe anxiety or depression [ ] Use of psychotropics (1.7)* [ ] Smoking

III. [ ] History of prior fall (3.0) [ ] Fall in past month [ ] Gait or balance deficit (2.9)* [ ] Use of assistive device (2.6) [ ] Impaired ADLs (2.3)*

IV. [ ] Living alone

(* indicates risk factor for fall injury also)

SUMMARY

I. MEDICAL/SURGICAL ISSUES (etiologies and other testing - categorized as cardiovascular, neurological, musculoskeletal, mechanical, accidental)

II. MENTAL STATUS/EMOTIONS/COPING (communication, preferences, ...)

III. PHYSICAL FUNCTION (therapies, assistive devices, ...)

IV. LIVING ENVIRONMENT (home eval, home equipment, family/caregiver, community resources, ...)

FOLLOW-UP

WELLNESS CLINIC

REASON FOR REFERRAL:

HPI:

PMH/PSH: |ACTIVE PROB LIST-SHORT|

DATA: CARDIAC SYMPTOMS: [ ]Chest pain (Ischemic) [ ]Orthopnea/PND [ ]Dizzy/Syncope [ ]Heart murmur [ ]Dyspnea [ ]Dyspnea on exertion [ ]Palpitations [ ]Ankle edema [ ]Claudication CRF(S): [ ]Tobacco [ ]HTN [ ]Hypercholesterolemia [ ]NIDDM [ ]IDDM [ ] Family History (Sx CAD/MI in males, 56 yo/females,66yo)

STRESS TEST Date/Type/Results (Max HR/ST; Change in BP; Change in Stopped For):

[ ]X-ray [ ]EMG [ ]CT/MRI [ ]ECG [ ]ECHO Date/Result:

EXAM: VITALS: (Seated at rest) HR: |PULSE| BP: |BLOOD PRESSURE| Ht: |PATIENT HEIGHT| Wt: |PATIENT WEIGHT| BMI: |BMI| CHEST: [ ]nl [ ]abnl (Rales/Wheezes/Rhonchi) HEART: [ ]nl [ ]abnl (Murmurs/Rubs/Gallops) EXTREM: [ ]nl [ ]abnl (ROM/Edema/Cyanosis/Clubbing) NEURO: [ ]nl [ ]abnl (Reflex/Motor/Sensory) Other:

PROVISIONAL DIAGNOSIS: (ICD9 CODE) I. [ ] Debility (799.3) II. [ ] Tobacco Dependence (305.1) III. [ ] Obesity (278.0)

ASSESSMENT:

PLAN: 1. STRESS TEST [ ]: (ORDER if age>40 and (a) + 3 CRFs (b) + 2 CRFs including DM or FHx or (c) Sx or CAD) 2. FOLLOW-UP: [ ] weeks in [ ]Wellness [ ]PM&RS/Building 500 [ ]Discharge 3. THR: [ ] @Low(20-40%) Moderate(40-60%) Vigorous(60-80%) level Calculate as below: A. 220 - Age = Maximal Heart Rate (Max HR) B. Max HR - Resting HR = HR Reserve (HRR) C. [(Desired % of HR) X HRR] + Rest = Target HR (THR) 4. RX: [ ]Back school [ ]Lumbar Stabilization [ ]Aerobic Conditioning [ ]Strength Training [ ]Stretching [ ]Ice [ ]Heat [ ]Home Exercise Program (1-2 visits only) [ ]Other (specify) 5. REFERRAL: [ ]Gen'l Rehab [ ]Cardiac Rehab [ ]Urgent Care [ ]Other (specify) 6. PRECAUTIONS: [ ]Rest + 20 bpm [ ]Other (specify):