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Tobacco Cessation Case Review for Patient with Psychiatric Comorbidities

Patient with psychiatric comorbidities seeking tobacco cessation support. Details include medication history, tobacco use, cessation medications past and present, and psychiatric symptoms status over the last 3 months. Requesting ECHO team's assistance in optimizing cessation strategies for this complex case.

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Tobacco Cessation Case Review for Patient with Psychiatric Comorbidities

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  1. Instructions to fill out this template • All participants must comply with HIPPA regulations and not use any Patient Identifiers when submitting cases for review • Please briefly describe relevant aspects of your case and draft your question (s) at the end of the presentation • Send this form before the next ECHO clinic so the facilitators have some time to review your case and provide valuable feedback • Email your completed form to Endtobacco@mdanderson.org Be advised that this ECHO consultation does not create or otherwise establish a provider- patient relationship between any MD Anderson clinician and any patient whose case is being presented in a Project ECHO setting

  2. Presenter’s name: Agency: Role/ Title • Patient’s age: • Gender: • Type of services provided (select): Office, Home or community, phone, other Assigned case #: Follow-up date:

  3. Co-morbidities • Chief complaint of the patient:

  4. Medications • List any medications: • Any Changes to psychiatric medications in the last 3 months? • No • Unknown • Yes, details: • Status of psychiatric symptoms in the last 3 months: • Stable • Partially stable • Unstable • Unknown

  5. Tobacco Use: (Indicate the amount of use) • Cigarettes: • Oral Tobacco: • Cigar: • Pipe: • E-cigarette: • Comments (Please include details as needed, such as how long they’ve been using tobacco products):

  6. Tobacco Cessation Medications (highlight all that apply) Past Use • Varenicline • Bupropion • Nicotine Patch • Gum • Lozenge • Nasal Spray • Inhaler • Other (explain) Present Use • Varenicline • Bupropion • Nicotine Patch • Gum • Lozenge • Nasal Spray • Inhaler • Other (explain)

  7. Questions/ Discussion/Other comments • • Please state your questions for the ECHO team Please describe what you would like the team to help you with

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