Care Mgt referral.

1. Care Mgt referral. --pt having difficulty with endo test and tx plans at PMC. Please help coordinate all plans from today's OV as pt is high risk.... Pt has no transportation. Endo office would like pt to have thyroid uptake and ablation. called nuclear med at LVH and uptake start at 8:15 in am and pt to return in 6 hrs and 24 hours later for the scan.

2. This option would not work as needs share a ride. called pmc, the pt would come in to take the capsule and would be there only a few minutes. This is done between 8 and 9:30 am only mon-fri. For scan she would come back same time next day. share a ride only runs 10am -2 pm. called pt and aware of issues and would like to have everything done at pmc, called pmc back and spoke to nuclear med and they do not perform ablation. plan at this point if pt is agreeable to it: have uptake done at PMC--friend to take her for these 2 visits. Have share a ride take her to lvh for ablation- problem is she will be picked up early, arrive at lvh around 10am and will be leaving lvh at about 1-2pm. will need to convince patient to do this. Plan B is to ask her friend to take her to this appt as will be at most a 2 hour visit, but likely 1 hr at LVH for ablation. Summary of Call: called pt with the information i obtained for the studies. gave her pmc sched 476-3495 to schedule thyroid uptake. she will call me back with the date. again stated it will depend on her transportation. will follow up tomorrow to make sure there was a date set. will also coordinate the ablation with lvh and endo office

3. Additional Follow-up Details: appt made for uptake August 9, 2011 10:41 AM Pt called stating there is a problem with her thyroid, Big mixup about today. August 11, 2011 11:42 AM Follow-up Details: called pmc scheduling, appt was cancelled today. spoke with tech and he was concerned about the protocol therapy could be different from that the lehigh valley hospital and lvh might want their own intake. would prefer that lvh confirm if will accept their uptake.Asked this tech where they send people they have done uptakes for and need an ablation and his response was LVH.He prefered I call LVH to confirm they would accept pmc uptake results. called lvh to inquire if they would accept the uptake,

4. called lvh nuclear med and will accept pmc uptake. should have tsh, t3, t4 before ablation. lvh will call to set up with her once scan is done. there fax for uptake 610-402-8910. endo needs to send a form to be completed and send to lvh. called endo office to let them know what her PCP’s office has been trying to set up. asked them to please call us back asap to set up arrangements. called pmc scheduling and they will call pt to reschedule, pt called back and is scheduled for uptake at pmc aug 17 &18. called endo office to notify them of uptake date and the need to set up ablation at lvh. Their nurse aware of uptake date and will let dr aware. plan to follow up to make sure ablation is set up at lvh. Returned call to endo office, phone accidentally answered by a nurse who put me on hold, after explaining I had a question regarding a mutual pt; waited on hold >10 min. Hung up and returned call, choosing the drs line option (#6), again waited on hold for approx 8 min, then call was picked up by a staff member, explained that I was inquiring to verify that pts ablation has been sched, per nurse conversation day before, No response received from Endo's office.

5. called endo office and left a voicemail message for someone to call the office back regarding the status of the appointment for the ablation. No response called the office again and was told that they (endo office) would not set up the appointment. i explained that the nurse there was to be working on this, the caller then said "let me transfer you to the nurses line". no answer on the nurses line, just the option to leave another message. i did not opt to leave another message, as i had just left a message a few minutes ago. August 15, 2011 4:18 PM Returned call to pt, who states that she had also called endo office today and did finally hear back from them. States they and she were very confused about what is going on, but that ultimately, endo office is going to sched the ablation at LVH. They will call her when this is done. Advised pt that I also had several calls to Endo today and haven't heard back from them. Requested that she provide the ablation date to us when she finds out from endo office. Pt verb understanding.

6. Current Problems (prior to this update): URINARY FREQUENCY (ICD-788.41) HYPOMAGNESEMIA (ICD-275.2) HYPERTENSION, BENIGN (ICD-401.1) PLEURAL EFFUSION, RIGHT (ICD-511.9) HYPERTHYROIDISM (ICD-242.90) ATRIAL FIBRILLATION (ICD-427.31) HIP FRACTURE, LEFT (ICD-820.8) PAIN IN THORACIC SPINE (ICD-724.1) ANEMIA (ICD-285.9) WEIGHT LOSS (ICD-783.21) HEPATIC CYST (ICD-573.8) RENAL CYST, LEFT (ICD-593.2) PULMONARY NODULE (ICD-518.89) THORACIC AORTIC ANEURYSM (ICD-441.2) OVARIAN MASS (ICD-625.8) ADJUSTMENT DISORDER WITH DEPRESSED MOOD (ICD-309.0) WEAKNESS (ICD-780.79) DYSPNEA ON EXERTION (ICD-786.09) CAROTID ARTERY STENOSIS, LEFT (ICD-433.10) ANXIETY (ICD-300.00) OSTEOPENIA (ICD-733.90) PROTEINURIA (ICD-791.0) MITRAL VALVE DISORDER (ICD-424.0) OTHER SPECIFIED GLAUCOMA (ICD-365.89) SJOGREN'S SYNDROME (ICD-710.2) Hx of ISCHEMIC COLITIS (ICD-557.9) Hx of CHRONIC KIDNEY DISEASE STAGE III (MODERATE) (ICD-585.3)

7. Current Problems: HYPERBILIRUBINEMIA (ICD-782.4) --resolved after stopping tapazol. URINARY FREQUENCY (ICD-788.41) --Pt verb waking up more often to urinate throughout the night. Started 4wks weeks ago. Does not happen during the day. no better s/p abx in June. HYPERTHYROIDISM (ICD-242.90) --saw endo in June. Given rx for radioactive update scan and radioactive iodine ablation. Did not get done yet due to transportaton. ATRIAL FIBRILLATION (ICD-427.31)on coumadin HIP FRACTURE, LEFT (ICD-820.8) --L hip pain continues. Recent fall at hospital and positive for fracture. Patient did not follow up with orth as did not like the care he provided. Was placed in short term rehab after fracture. DEPENDENT EDEMA, LEGS, BILATERAL (ICD-782.3) --continues to have LLE lump - actually edema WEIGHT LOSS (ICD-783.21) -eating well. but having probs gaining wgt.

8. Patient had ablation without incident and was able to come off her coumadin due to this. Ekg was normal, no A-Fib noted. HIP FRACTURE, LEFT (ICD-820.8) --Asked by Dr Terpstra to eval pt pre-op clearance. Pt has L hip femoral neck fx, will sched surgery at the Surgical Specialty Center to complete L hip removal of hardware (from prev surgery) with Hemiarthroplasty. Pt unaware of anything ordered for pre-op clearance. Pt reports pain as a 9 on the pain scale. States taking percocet with minimal relief of pain. Denies SE - no nausea or lightheadedness or constipation. Pt states not having a cardiologist to go to for cardiac clearance, needs to wean off plavix and coumadin prior to suregry. Pt would like to receive the annual flu vaccine. Current Problems: HYPERBILIRUBINEMIA (ICD-782.4) --resolved HYPERTENSION, BENIGN (ICD-401.1) --no CP, SOB HYPERTHYROIDISM (ICD-242.90) --s/p ablation - went well. ATRIAL FIBRILLATION (ICD-427.31) --Taking propranolol, one tab daily vs 1/2 tab BID. no unusual bleeding. DEPENDENT EDEMA, LEGS, BILATERAL (ICD-782.3) --small area - no change TRANSAMINASES, SERUM, ELEVATED (ICD-790.4) --resolved off tapazole CHRONIC KIDNEY DISEASE STAGE III (MODERATE) (ICD-585.3) --GFR ok last time ANEMIA (ICD-285.9)

9. renal function slightly worse, but overall stable. CBC shows decrease in HgB. I'd advise non-urgent transfusion next week before surgery scheduled. Please check with hematolgy to see if they agree and can help arrange transfusion as I only have privledges at LVH and pt will not go all the way there for transfusion. Reviewed results and instructions with pt who verb understanding. Pt express frustration with transportation issues. Reviewed with pt that it would be more time efficient to have transfusion with LVH, as PCP can order for an appt time for her to receive. If going thru any other facility, would need to go thru the ER for tx. Pt states having an appt 10/4 with CHS to sched surgery. Pt aware needs to have transfusion prior to surgery. Per PCP, transfusion is non-urgent. Pt going to try to arrange transportation over the weekend and decide which facility she would like to go to to receive. Pt to call on Monday with an update. Pt wanting to know if she can be admitted to the hospital the day before her surgery is sched to receive the transfusion. PCP states would be ok just check with the surgeon. Called surgeon and left detailed message If this doesn't work, requesting his suggestions. (His receptionist states according to the scheduler, surgeon does surgery at LVH-M, but this is very rare. Surgeon states plan to admit the pt the day prior to surgery to receive the transfusion is ok, and accomodations to do this at LVH can also be made. Requesting a letter with PCP recommendations, including orders, and lab report be faxed to their office. PCP advises consulting hospitalist on the pre-op day so they can help manage transfusion and renal function pre and post-op.

10. Called and spoke with Pt who stated she was informed by Endo that she cannot have surgery for at least 2 mos after last ablation. Pt stated she is scheduled for Oct 27th. Additional Follow-up Details: Then she received a message from Endo stating that she should have labs done in 2 wks to determine if she can have the surgery. Pt states that she is very confused, and that her tentative appt for surgery is 10/27, she is feeling uncomfortable with ortho right now as they should have known this. Asked pt to complete labs as directed by Endo, Pt states that her hip pain is a 10 on the pain scale, taking percocet make it about a 6. clarified with endo earliest possible surgery date given pt has hip fx and 10/10 pain on meds. 2 mos would be mid Nov? Called Endo office and had to leave message Called Endo office again and spoke with His Nurse Explained to the nurse pt was told she had to delay surgery until 2 mos after last ablation. The nurse stated she knows nothing about this and I would need to speak with the Dr and will call back tolet us know when she can have surgery.