Hospital Initial assessment

Date of admission: 1 November 2024 Room number: 305 Health Card number: 123456789 Reason for Palliation: Advanced metastatic cancer Code Status: DNIR Referring physician: Dr. John Smith Family physician: Dr. Emily Brown **Living Situation and functional status:** Apartment, requires assistance with ADLs, uses a walker, independent with banking and cooking **Medical Power of Attorney/SDM/NOK:** Daughter, Jane Doe **Recent medical illness course:** Recent hospitalization for pneumonia **On Exam and Wounds:** Heart rate 88 bpm, blood pressure 120/80 mmHg, oxygen saturation 95%, resp rate 18, temperature 37°C, abdomen soft, clear breath sounds, normal heart sounds, no murmurs, mild oedema in lower extremities, no wounds **Past medical history:** Hypertension, Type 2 Diabetes, Chronic Kidney Disease **Labs:** Sodium 140 mmol/L, Creatinine 1.5 mg/dL, Liver enzymes normal, Albumin 3.5 g/dL **Imaging results:** Echocardiogram shows normal function, CT scan reveals metastatic lesions in the liver **Specialist consultations:** Oncologist, Nephrologist **Ins and Outs:** Regular bowel movements, adequate food intake, eats breakfast, lunch, and dinner Medications: Metformin, Lisinopril, Furosemide ESAS: Pain - Moderate ache Tiredness - Moderate fatigue Drowsiness - Mildly sleepy Nausea - Occasional vomiting Lack of Appetite - Food doesn't taste the same SOB - Mild shortness of breath Depression - Low mood Anxiety - Mild stress Best Well Being - 5/10 Sleep - 6 hours per night Bowel movements - Regular **Religion:** Christian Goals of care: Focus on comfort and quality of life, avoid aggressive treatments **Overall impression and Plan:** To summarize, the patient is in the palliative stage of metastatic cancer with a focus on symptom management and quality of life. The plan is to continue current medications, monitor symptoms, and provide supportive care.