Rotation 7 H&Ps

Rotation 7 H&Ps

 

History and Physical 1

 

Identifying Data:

  • Name: DH
  • Sex: Male
  • Age: 57 years
  • Date and Time: 9/25/2020, 9:15 AM
  • Location: Far Rockaway Center for Rehabilitation and Nursing
  • Source of Information: Self, patient chart

 

Chief Complaint:

Left foot wound x 3 weeks

 

History of Present Illness:

DH is a 57-year-old Caucasian male current smoker (12.5 pack years) with a significant PMHx of T2DM (uncontrolled),  non-healing bilateral lower extremity ulcers and associated chronic left foot pain s/p left first transmetatarsal and second toe amputations, asthma, and chronic venous insufficiency, and a significant past psychiatric history of depression, anxiety, schizoaffective disorder, and polysubstance abuse (heroin, alcohol, and nicotine). Of note, DH admits to heroin relapse 1 week prior to symptom onset. He presented to Mount Sinai Hospital (Queens) on 9/8/2020 complaining of left foot pain associated with an open wound. He endorsed worsening purulent drainage, erythema, edema, and pain in the affected area and had difficulty putting weight on his left foot. He was previously able to ambulate freely without assistance. DH admits that he was previously following with his podiatrist concerning his diabetic foot wounds for maintenance and wound dressings but has not properly cared for his wounds since his heroin relapse. He denied any other acute complaints, chest pain, palpitations, SOB, nausea, vomiting, diarrhea, constipation, blood in urine or stool, irritative voiding symptoms, headache, dizziness, fever, or chills at the time of presentation. Clinical presentation and imaging of the left lower extremity were consistent with acute on chronic osteomyelitis of the left foot with abscess and gas gangrene.

During his hospital course, DH had an I&D of the wound with a positive wound culture for MRSA and E. faecalis. A double lumen PICC line was placed in the right basilic vein for long-term vancomycin administration. He was consistently afebrile with stable vital signs. Pain control was managed with PO Tylenol and oxycodone. Patient refused suboxone/methadone during his hospitalization and was monitored for opioid withdrawal symptoms. DH was medically cleared for discharge and transferred to Far Rockaway Center for Rehabilitation and Nursing (FRCRN) for nursing services and rehabilitation on 9/18/2020.

Currently, DH complains of mild pain in his left foot that is well controlled on his current pain regimen (Tylenol and oxycodone). Since his admission to FRCRN, he has remained stable and afebrile with normal vital signs. His wound is being closely monitored nightly by the wound care team with daily dressing changes. Overnight, his PICC line was displaced and was replaced with a single lumen PICC line in the left basilic vein and has been continued on the antibiotic regimen initiated at Mount Sinai Hospital. He states that he is feeling well and is eager for discharge. He continues to deny subjective fevers, chills, body aches, SOB, coughing, chest pain, changes in bowel habits, irritative voiding symptoms, nausea, vomiting, or any other symptoms. DH is tolerating a full diet. DH is able to ambulate with support and in a wheelchair. He is full code.

 

Past Medical History:

  • Present Illnesses:
  1. Diabetes Mellitus Type II x 10 years
    1. Poorly controlled, not compliant with medications
    2. Associated non-healing diabetic foot wounds – previously following with podiatrist
  2. Chronic venous insufficiency
  3. Asthma – since childhood
    1. Last attack “many years ago”
    2. Not currently on maintenance medications
  4. Schizoaffective Disorder
    1. Not currently following with psychiatrist or taking medications
  5. Major Depressive Disorder
  6. Anxiety
  7. Polysubstance abuse
    1. Heroin, nicotine, and alcohol
  • Past Illnesses:
    • Denies any past illnesses
  • Hospitalizations:
    • See HPI
    • Hospitalized at Mount Sinai Hospital in 2017 for non-healing foot wounds
      • S/p foot amputations x 2
    • Immunizations:
      • Childhood immunizations up to date
      • Does not receive annual influenza vaccination
    • Screenings:
      • Has never had a colonoscopy
      • Last DRE last year – unremarkable
      • Vision screen last year – no need for vision correction

 

Past Surgical History:

  • Left first transmetatarsal and second toe amputations – 2017
    • Mount Sinai Hospital, unable to provide surgeon’s name
    • Healed well, no complications

 

Medications:

  1. Vancomycin (Vancocin) 1g IV via PICC line in 200 mL 5% dextrose BID
    1. Last dose this morning
  2. Insulin glargine (Lantus) 100 unit/mL 42 units SC injection
    1. Last dose this morning
  3. Insulin lispro (Humalog) 100 unit/mL SC injection sliding scale TID with meals
    1. Last dose last night with dinner
  4. Acetaminophen (Tylenol) 650 mg PO Q6hours PRN
    1. Last dose last night
  5. Oxycodone (Roxicodone) immediate release 5mg PO Q6hours PRN
    1. For mild pain (3-6/10)
    2. Last dose this morning
  6. Oxycodone (Roxicodone) immediate release 10 mg PO Q6hours PRN
    1. For severe pain (7-10/10)
    2. Last dose yesterday evening
  7. Trazodone 150 mg PO QD at bedtime
    1. Last dose last night
  8. Polyethylene glycol (Miralax) 17 g packet PO QD
    1. Last dose this morning

 

Allergies:

DH denies any known allergies to medications, foods, or environmental factors

 

Family History:

Noncontributory.

 

Social History:

DH is a 57-year-old unmarried male who lives alone in an apartment. He is currently unemployed and states that he used to work in construction. He denies having any family but provided the contact information of a close friend as an emergency contact. He admits to using heroin every day starting 1 week prior to his symptom onset. He also admits to being a current cigarette smoker and has smoked half a pack of cigarettes daily for the last 25 years (12.5 pack years). He shows no interest in smoking cessation. He drinks beer “a couple times a week.” He reports that he is active because he “walks everywhere” and does not have a car. He admits to eating 3 meals daily prior to his admission and does not maintain a diabetic diet. He reports that he sleeps poorly (3-4 hours per night). He is not currently sexually active but, in the past, has only been sexually active with women with occasional condom use. He denies any recent travel and uses all appropriate safety measures.

 

Review of Systems:

General:

Denies fever, chills, night sweats, fatigue, weakness, loss of appetite, and recent weight gain or loss

Skin, hair, nails:

Reports numerous non-healing wounds on his bilateral lower extremities, most severe on his left foot with erythema and purulent drainage. Denies changes in texture, excessive dryness or sweating, discolorations, pigmentations, moles/rashes, pruritus, changes in hair distribution

Head:

Denies headache, vertigo, head trauma, unconsciousness, coma, fracture

Eyes:

Denies use of contacts lenses or glasses, visual disturbances, fatigue, lacrimation, photophobia, and pruritus. He reports that his last vision check was last year

Ears:

Denies deafness, pain, discharge, tinnitus, and use of hearing aids

Nose/Sinuses:

Denies discharge, epistaxis, and obstruction

Mouth and throat:

Denies bleeding gums, sore tongue, sore throat, mouth ulcers, voice changes, and use of dentures. Reports that he has not seen a dentist in “a while”

Neck:

Denies localized swelling/lumps, stiffness, and decreased range of motion

Pulmonary:

Denies dyspnea, SOB, cough, wheezing, hemoptysis, cyanosis, orthopnea, and PND

Cardiovascular:

Denies chest pain, palpitations, irregular heartbeat, syncope, and known heart murmur

Gastrointestinal:

Denies changes in appetite, intolerance to foods, nausea and vomiting, dysphagia, pyrosis, flatulence, eructation, abdominal pain, diarrhea, change in bowel habits, hemorrhoids, constipation, rectal bleeding, and blood in stool. He has never had a colonoscopy

Genitourinary:

Denies urinary frequency, changes in color of urine, incontinence, dysuria, nocturia, urgency, and oliguria. His last DRE was last year and was unremarkable

 

Musculoskeletal:

Reports left foot swelling, pain, and erythema. Denies muscle/joint pain, deformity, and arthritis

Peripheral Vascular:

History of chronic venous insufficiency and bilateral lower leg ulcers. Denies intermittent claudication, coldness, and color changes

Hematologic:

Denies anemia, easy bruising or bleeding, lymph node enlargement, and history of DVT/PE

Endocrine:

History of poorly controlled T2DM. Denies polyuria, polydipsia, polyphagia, heat or cold intolerance, and goiter.

Nervous System:

Denies seizures, loss consciousness, sensory disturbances, ataxia, loss of strength, change in cognition/mental status/memory, and weakness

Psychiatric:

History of depression, anxiety, polysubstance abuse, and schizoaffective disorder. Denies feelings of depression/sadness, anhedonia, obsessions, compulsions, and visual/auditory hallucinations. He has seen a psychiatrist in the past but does not currently follow with one.

 

Physical Exam:

Vital Signs:

Blood Pressure: 126/77 (left arm, sitting)

Heart Rate: 83 beats/minute (regular)

Respiration Rate: 18 breaths/minute (nonlabored)

Temperature: 97.7 F (oral)

O2 Sat: 100% (room air)

Height: 76 inches

Weight: 163 lbs

BMI: 19.84

General Appearance:

57-year-old well-nourished male dressed appropriately with good hygiene seen in wheelchair in assigned room. A&O x 3. Calm and cooperative. Wound dressing on left foot and PICC line in place on left arm. In no acute distress.

Skin:

Skin is warm and moist with good turgor and no discoloration throughout. Evidence if IV drug use bilaterally on forearms and antecubital areas. Multiple dry, scabbed ulcers on bilateral lower legs. Wound dressing covering left foot clean, dry, and intact.

Nails:

No clubbing, signs of infection, capillary refill <2 sec throughout.

Hair:

Frontal hair thinning; otherwise unremarkable

Head:

Normocephalic and atraumatic. Nontender to palpation throughout, without signs of alopecia, seborrhea, or lice.

Eyes:

Symmetrical OU without evidence of strabismus or ptosis. Sclera white, conjunctiva pink, and cornea clear. Visual fields full bilaterally. PERRLA. EOMI without nystagmus

Visual Acuity: Not assessed.

Fundoscopy: Not assessed.

Ears:

Symmetrical and normal size. No evidence of lesions, masses, or trauma on external ears. No discharge, foreign bodies in external auditory canals AU. TMs pearly gray and intact with light reflex in appropriate position AU. Auditory acuity intact to whisper AU.

Nose:

Symmetrical without obvious masses, lesions, deformities, trauma, or discharge. Nares patent bilaterally. Nasal mucosa pink & well hydrated. No discharge noted on anterior rhinoscopy. Septum midline without lesions, deformities, injection, or perforation. No evidence of foreign bodies.

 

Sinuses:

Nontender to palpation and percussion over bilateral frontal and maxillary sinuses.

 

Mouth and Pharynx:

Lips: Pink, moist, no evidence of cyanosis or lesions.

Mucosa: Pink; well hydrated. No masses or lesions noted.

Palate: Pink, well hydrated. Palate intact without lesions, masses, or scars.

Teeth: Good dentition without obvious dental caries noted.

Gingiva: Pink and moist without evidence of hyperplasia, masses, lesions, erythema, or discharge.

Tongue: Pink and well papillated. No masses, lesions, or deviation noted.

Oropharynx: Well hydrated and without evidence of injection, exudates, masses, lesions, foreign bodies. Tonsils present with no evidence of injection or exudate. Uvula pink without edema or lesions.

Neck:

Trachea midline. No masses, lesions, scars, or abnormal pulsation noted. Supple, nontender to palpation. FROM. No stridor noted. Thyroid non-tender, no palpable masses, no thyromegaly.

Chest:

Symmetrical without deformities or signs of trauma. Respiration unlabored and without use of accessory muscles. Lateral : AP diameter 2:1. Non-tender to palpation.

Lungs:

Clear to auscultation bilaterally without adventitious lung sounds.

Cardiovascular:

Regular rate and rhythm. S1 and S2 present. There are no murmurs, S3, S4, splitting of heart sounds, friction rubs, or other extra sounds. Carotid pulses ae 2+ bilaterally without bruits.

Abdomen:

Flat and symmetrical without evidence of scars, striae, caput medusae or abnormal pulsations. BS present in all 4 quadrants. Tympanic to percussion throughout. Non-tender to percussion or to light/deep palpation. No evidence of organomegaly. No masses noted. No evidence of guarding or rebound tenderness.   No CVAT noted bilaterally.

Genitourinary:

         Not assessed.

Rectal:

 

Not assessed.

Peripheral Vascular:

Extremities are normal in color, size and temperature. Pulses are 2+ bilaterally in upper and lower extremities (left DP pulse not assessed). No bruits noted. No clubbing, cyanosis or edema noted bilaterally. Multiple dry, scabbed over ulcers on lower extremities bilaterally. Open wound on left foot covered with bandage; bandage clean, dry, and intact.

Musculoskeletal:

Left foot s/p left first transmetatarsal and second toe amputations; stumps healed well. Mild swelling in left foot surrounding open wound. All other extremities unremarkable in appearance. Mild tenderness to palpation in the left foot. FROM of upper and lower extremities bilaterally. Muscle strength 5/5 throughout.

Neurological:

Mental Status:

Alert and oriented to person, place and time. Memory and attention intact. Receptive and expressive abilities intact. Thought coherent. No dysarthria, dysphonia or aphasia noted. Follows commands. Exhibits good insight and judgment throughout interview (acknowledges that his fingerstick glucose numbers have been high because he has not been watching his diet, but will modifty his carb intake so they improve and his wound heals well).

Cranial Nerves:

I – Intact no anosmia.

II- Visual acuity not assessed. Visual fields by confrontation full. Fundoscopy not assessed.

III-IV-VI- PERRLA, EOM intact without nystagmus.

V- Facial sensation intact, strength good.

VII- Facial movements symmetrical and without weakness.

VIII- Hearing grossly intact to whispered voice bilaterally.

IX-X-XII- Swallowing intact. Uvula elevates midline. Tongue movement intact.

XI- Shoulder shrug intact. Sternocleidomastoid and trapezius muscles strong.

Motor/Cerebellar:

Patient observed freely ambulating around facility with cane. Full active and passive ROM of all extremities without rigidity or spasticity. Normal muscle bulk and tone. No atrophy, tics, tremors or fasciculations. Strength equal and appropriate for age bilaterally. Gait normal with no ataxia.

Sensory:

Intact to light and sharp touch, sharp/dull, point localization, and extinction.

Reflexes:

            Not assessed.

Meningeal Signs:

No nuchal rigidity noted. Brudzinski’s and Kernig’s signs negative.

 

Labs:

X-ray and CT scan of left foot from hospital course display subcutaneous emphysema, periosteal thickening, and abscess consistent with acute on chronic osteomyelitis.

Wound culture – positive for MRSA and E. faecalis

CBC – significant for down trending leukocytosis. H&H and platelets within normal limits

CMP – serum glucose consistently elevated, all other values within normal limits

Fingerstick glucose – most recent 341 mg/dL

 

 

Assessment:

DH is a 57-year-old Caucasian male current smoker (12.5 pack years) with a significant PMHx of T2DM (uncontrolled),  non-healing bilateral lower extremity ulcers and associated chronic left foot pain s/p left first transmetatarsal and second toe amputations, asthma, and chronic venous insufficiency, and a significant past psychiatric history of depression, anxiety, schizoaffective disorder, and polysubstance abuse (heroin, alcohol, and nicotine) admitted to FRCRN following hospitalization for left foot MRSA osteomyelitis as demonstrated by x-ray and CT scan findings and wound culture. S/p I&D of wound. He is tolerating PICC line delivered antibiotic treatment well with subjective improvement of symptoms and downtrending leukocytosis. In no acute distress.

 

Plan:

  1. MRSA Osteomyelitis, left foot – s/p I&D
    1. Continue IV vancomycin via PICC line x 6 weeks
    2. Continue current pain regimen and reassess pain needs as needed
    3. Wound care
      1. Change wound dressings nightly or sooner if dressings become soiled
    4. Weight bearing encouraged as tolerated with cane
      1. Physical therapy following
      2. Wheelchair available
    5. Continue monitoring daily labs
  2. Type 2 Diabetes Mellitus
    1. Continue current insulin regimen
    2. Diet modification discussed with patient; patient agrees and appears motivated to cut down on carbs
    3. Continue monitoring fingerstick glucose and daily labs
  3. Polysubstance abuse
    1. Heroin
      1. Continue to monitor for symptoms of withdrawal despite current oxycodone administration
      2. Counselled on risk and cessation
        1. Patient agreed and appears motivated not to relapse upon discharge
      3. Tobacco
        1. Currently still smoking cigarettes in facility’s smoking area
        2. Counselled on smoking cessation, but appears unwilling to quit at this time
      4. Alcohol
        1. Negative CAGE questionnaire
        2. Does not acknowledge a drinking problem
      5. Schizoaffective disorder
        1. Not currently managed on medications
        2. Psychiatry referral ordered
      6. Anxiety
        1. Not currently managed on medications
        2. Psychiatry referral ordered
      7. Depression
        1. Continue trazodone
        2. Psychiatry referral ordered
      8. Evaluation for safe discharge following completion of antibiotic regimen
        1. To be discussed with patient and emergency contact (patient’s friend) via social work team

 

  1. Continue full diet as tolerated
  2. Monitor for normal bowel function due to opioid analgesia
  3. Monitor vitals daily
  4. Encouraged to bring up any questions and concerns with facility staff
  5. Full code

 

 

 

 

History and Physical 2

 

Identifying Data:

  • Name: CA
  • Sex: Female
  • Age: 83 years
  • Date and Time: 10/2/2020, 10:00 AM
  • Location: Far Rockaway Center for Rehabilitation and Nursing
  • Source of Information: Self, patient chart

 

Chief Complaint:

Left leg pain x 2 days

 

History of Present Illness:

CA is an 83-year-old unreliable, bilingual (Castilian Spanish [preferred] and English), widowed Hispanic female with a significant past medical history of T2DM with diabetic neuropathy, hyperthyroidism, PVD with chronic left lower extremity DVT, osteomyelitis s/p left great toe amputation, COPD, dementia with behavioral disturbance, generalized muscle weakness, and CAD s/p cardiac pacemaker complaining of left lower leg pain x 2 days. Prior to admission to Far Rockaway Center for Rehabilitation and Nursing (FRCRN) in July 2018, CA was admitted to St. John’s Episcopal Hospital from another skilled nursing facility for evaluation and treatment of a left great toe wound and osteomyelitis following a traumatic injury where the patient reports that another resident ran over her toe with a wheelchair 2 days prior. While she was previously able to ambulate with the assistance of a straight cane, she was experiencing acute difficulty ambulating. Upon evaluation and imaging, there was evidence of bone exposure and muscle necrosis. She was treated with IV antibiotic therapy and had a left hallux amputation on 6/28/2018. She was discharged to FRCRN in July 2018, where she has since resided without other incidents requiring hospitalization.

Currently, CA is complaining of left lower leg pain x 2 days. She also reports swelling, erythema, and a new “bump” on the medial surface of her left calf. She denies loss of sensation and endorses pain with movement. The nursing staff report a slight but noticeable change in mental status and increased lethargy today. She was treated with 2 days of Keflex 500 mg PO BID without improvement of her condition. Her vital signs have been stable and she has remained afebrile. She denies subjective fevers, chills, chest pain, cough, SOB, changes in bowel habits, irritative voiding symptoms, or any other symptoms. She has become slightly more combative with her roommate in the last few days and has a history of multiple resident-to-resident incidents.

CA is tolerating a low-carbohydrate and low sodium diet and takes fluids by mouth. Currently only ambulates in a wheelchair; on fall precaution. She is able to feed herself and swallow but needs assistance with other ADLs. She is full code.

 

Past Medical History:

  • Present Illnesses:
  1. Type 2 Diabetes Mellitus with diabetic neuropathy
    1. Unable to provide information about when she was diagnosed due to either being unable to understand or unaware of diagnosis; date of diagnosis unavailable in patient’s chart
    2. Managed on metformin; gabapentin for neuropathy
    3. Follows with endocrinologist annually – last follow-up 9/14/2020
  2. Hyperthyroidism

 

 

  1. Unable to provide information about when she was diagnosed; date of diagnosis unavailable in patient’s chart
  2. Managed on methimazole
  3. Follows with endocrinologist annually – last follow-up 9/14/2020
  1. Peripheral vascular disease with chronic left DVT – since 2013 as per patient’s chart
    1. Anticoagulated on Eliquis
  2. Chronic obstructive pulmonary disease
    1. Unable to provide information about when she was diagnosed; date of diagnosis unavailable in patient’s chart
    2. Managed on DuoNeb and respiratory care program
  3. Dementia with behavioral disturbance
    1. Unable to provide information about when she was diagnosed; date of diagnosis unavailable in patient’s chart
  4. Coronary artery disease s/p permanent cardiac pacemaker
    1. Unable to provide information about when she was diagnosed with CAD; date of diagnosis unavailable in patient’s chart
    2. Reason for pacemaker unclear in chart; implanted 6/1/2017
      1. Guidant L311 dual lead left chest wall pacer; serial number 291497
      2. Last evaluated 7/29/2019 – battery status normal with normal function
    3. Managed on Rosuvastatin
  5. Schizoaffective disorder
    1. Date of onset unknown
    2. Managed on Risperidone
  • Past Illnesses:
  1. Chronic osteomyelitis, left hallux – 2018
    1. Treated at Kings County Hospital and St. John’s Episcopal Hospital
    2. S/p left hallux amputation 6/28/2018
  • Hospitalizations:
  1. Osteomyelitis – 2018
    1. See HPI
  2. Hospitalizations for cardiac issues – inferred from chart, but no specific information
    1. Patient unable to provide further information
  • Immunizations:
    • Childhood immunizations up to date
    • Receives influenza vaccination annually
    • Received pneumonia vaccine
  • Screenings:
    • EKG – 7/29/2019
      • Normal sinus rhythm with permanent pacemaker
    • Colonoscopy – no information available in patient’s chart
    • Dental – 7/22/2020
      • Maxillary denture in place
      • Fair oral hygiene without complaints
    • Hearing – 8/6/2019
      • Conductive hearing loss in right ear
      • Oticon Opn3FS hearing aid dispensed for right ear
    • No information available on last pap smear and mammogram

 

Past Surgical History:

  1. Left hallux amputation – 6/28/2018
    1. See HPI

 

  1. John’s Episcopal Hospital – surgeon’s name unavailable

 

  1. Healed well without complications
  1. Permanent cardiac pacemaker placement – 6/1/2017
    1. Kings County Hospital – surgeon’s name unavailable
    2. Healed well without complications

No record of other injuries, surgeries, or transfusions

 

Medications:

  1. Acetaminophen (Tylenol) ER 650 mg PO Q6hrs PRN
    1. For pain
  2. Apixaban (Eliquis) 5mg PO BID
    1. Chronic DVT
    2. Last dose this morning
  3. Rosuvastatin Calcium (Crestor) 20mg PO QD at bedtime
    1. CAD
    2. Last dose last night
  4. DuoNeb 0.5-2.5 (3) mg/ 3mL solution nebulizer Q8hours
    1. COPD
    2. Last dose yesterday afternoon
  5. Metformin HCl 850 mg PO BID
    1. T2DM
    2. Last dose this morning
  6. Methimazole 10 mg PO TID
    1. Hyperthyroidism
    2. Last dose this morning
  7. Gabapentin 100 mg PO TID
    1. Diabetic neuropathy
    2. Last dose this morning
  8. Risperidone 1 mg PO BID
    1. Schizoaffective disorder
    2. Last dose this morning

 

Allergies:

CA denies any known allergies to medications, foods, or environmental factors

 

Family History:

Patient unable to provide and information unavailable in chart

 

Social History:

CA is an 83-year-old bilingual (Castilian Spanish and English) speaking female. Due to her dementia diagnosis, she is an unreliable historian. She is a widow and has no next of kin as per her chart. She has been

 

living in skilled nursing facilities for at least 5 years based on chart review. As per the patient, she has never smoked, taken any illicit drugs, or drunk alcohol. She is not currently sexually active and cannot recall when she was last. In the past, she only had one sexual partner (her husband). She does not have any children. She denies any sleep disturbances and reports that she eats “a lot.” She is menopausal with no other available information.

 

Review of Systems:

            Unable to properly assess due to dementia and potential language barrier despite being spoken to in both English and Spanish; patient appears unable to understand questions and speaks about mostly unrelated topics. Repeatedly endorses pain in leg, but unable to provide more information.

 

Physical Exam:

Vital Signs:

Blood Pressure: 146/88 (right arm, sitting)

Heart Rate: 91 beats/minute (regular)

Respiration Rate: 18 breaths/minute (nonlabored)

Temperature: 98.7 F (oral)

O2 Sat: 94% (room air)

Height: 64 inches

Weight: 161 lbs

BMI: 27.6

General Appearance:

83-year-old well-nourished female dressed appropriately with average hygiene seen sitting up in bed. A&O x 1. Calm and cooperative. Appears more lethargic than previous encounters. Limited ability to answer questions and follow commands due to dementia diagnosis.

Skin:

Skin is warm and moist with appropriate turgor throughout. Left lower leg slightly warmer than right; see peripheral vascular. Bilateral lower extremities appear hyperpigmented. No concerning skin lesions or open wounds observed

Nails:

No clubbing or signs of infection. Capillary refill <2 sec throughout in fingers. Capillary refill >2 sec in toes.

Hair:

Hair quantity appears diminished throughout. Unremarkable texture.

Head:

Normocephalic and atraumatic. Nontender to palpation throughout, without signs of alopecia, seborrhea, or lice.

Eyes:

Wearing glasses. Symmetrical OU without evidence of strabismus or ptosis. Sclera white, conjunctiva pink, and cornea clear. Unable to assess visual fields. PERRL. EOMI without nystagmus

Visual Acuity: Not assessed.

Fundoscopy: Not assessed.

Ears:

Right hearing aid in place. Symmetrical and normal size. No evidence of lesions, masses, or trauma on external ears. No discharge, foreign bodies in external auditory canals AU. TMs pearly gray and intact with light reflex in appropriate position AU. Auditory acuity not assessed.

Nose:

 

 

 

Symmetrical without obvious masses, lesions, deformities, trauma, or discharge. Nares patent bilaterally. Nasal mucosa pink & well hydrated. No discharge noted on anterior rhinoscopy. Septum midline without lesions, deformities, injection, or perforation. No evidence of foreign bodies.

Sinuses:

Nontender to palpation and percussion over bilateral frontal and maxillary sinuses.

Mouth and Pharynx:

Lips: Pink, moist, no evidence of cyanosis or lesions.

Mucosa: Pink; well hydrated. No masses or lesions noted.

Palate: Pink, well hydrated. Palate intact without lesions, masses, or scars.

Teeth: Maxillary denture in place. Absent tooth #30. Adequate oral hygiene.

Gingiva: Pink and moist without evidence of hyperplasia, masses, lesions, erythema, or discharge.

Tongue: Pink and well papillated. No masses, lesions, or deviation noted.

Oropharynx: Well hydrated and without evidence of injection, exudates, masses, lesions, foreign bodies. Tonsils present with no evidence of injection or exudate. Uvula pink without edema or lesions.

Neck:

Trachea midline. No masses, lesions, scars, or abnormal pulsation noted. Supple, nontender to palpation. FROM. No stridor noted. Thyroid non-tender, no palpable masses, no thyromegaly.

Chest:

Symmetrical without deformities or signs of trauma. Scar on left upper chest from pacemaker implantation; device palpable under skin. Respiration unlabored and without use of accessory muscles. Lateral : AP diameter 2:1. Non-tender to palpation.

Lungs:

Clear to auscultation bilaterally without adventitious lung sounds.

Cardiovascular:

Regular rate and rhythm. S1 and S2 present. There are no murmurs, S3, S4, splitting of heart sounds, friction rubs, or other extra sounds. Carotid pulses ae 2+ bilaterally without bruits.

Abdomen:

Flat and symmetrical without evidence of scars, striae, caput medusae or abnormal pulsations. BS present in all 4 quadrants. Tympanic to percussion throughout. Non-tender to percussion or to light/deep palpation. No evidence of organomegaly. No masses noted. No evidence of guarding or rebound tenderness.   No CVAT noted bilaterally.

Genitourinary:

         Not assessed.

Rectal:

Not assessed.

Peripheral Vascular:

S/p left great toe amputation. Bilateral lower legs appear dusky bilaterally with waxy appearance and diminished hair growth. Left lower extremity edematous and erythematous extending from approximately 2 cm below the knee distally. Left lower leg warmer than right.  Pulses are 2+ bilaterally in upper extremities. Femoral pulses 2+ bilaterally. Right popliteal pulse 2+, left popliteal pulse 1+. Right DP and PT pulses 1+. Left DP pulse nonpalpable, left PT pulse 1+. No bruits noted. 1.5 cm diameter blister observed on left medial lower leg, 6.5 cm below knee.

Musculoskeletal:

Left foot s/p left great toe amputation; stump healed well. See peripheral vascular. All other extremities unremarkable in appearance. Tenderness with palpation of the left lower leg. FROM of upper and lower extremities bilaterally. Muscle strength 5/5 throughout.

Neurological:

Mental Status:

Alert and oriented to person only. Memory and attention moderately impaired. Receptive ability questionable and expressive abilities intact. No dysarthria, dysphonia or aphasia noted. Does not follow commands consistently. Exhibits poor insight and judgment throughout interview. Appears easily irritated by roommate and tells her to “take a walk” constantly during the interview.

Cranial Nerves:

I – Intact no anosmia.

II- Visual acuity not assessed. Unable to assess visual fields due to lack of understanding on patient’s part. Fundoscopy not assessed.

III-IV-VI- PERRL, EOM intact without nystagmus.

V- Facial sensation intact, strength good.

VII- Facial movements symmetrical and without weakness.

VIII- Hearing not assessed.

IX-X-XII- Swallowing intact. Uvula elevates midline. Tongue movement intact.

XI- Shoulder shrug intact. Sternocleidomastoid and trapezius muscles strong.

Motor/Cerebellar:

Patient currently non weight-bearing due to pain, so gait not assessed.. Full active and passive ROM of all extremities without rigidity or spasticity. Normal muscle bulk and tone. No atrophy, tics, tremors or fasciculations. Strength equal and appropriate for age bilaterally.

Sensory:

Unable to assess due to lack of understanding on the patient’s part.

Reflexes:

            Not assessed.

Meningeal Signs:

No nuchal rigidity noted. Brudzinski’s and Kernig’s signs negative.

 

Mini Mental Status Exam:

5
0
0
0
0
0
1 – pen
0
0
3 – pen, cup, chair
1
0

 

Labs:

  • CBC – leukocytosis to 18.4 with left shift
  • CMP within normal limits
  • Finger-stick glucose numbers stable between 140 and 230

 

Assessment:

CA is an 83-year-old unreliable, bilingual (Castilian Spanish [preferred] and English) Hispanic female with a significant past medical history of T2DM with diabetic neuropathy, hyperthyroidism, PVD with chronic

 

Left lower extremity DVT, osteomyelitis s/p left great toe amputation, COPD, dementia with behavioral disturbance, generalized muscle weakness, and CAD s/p cardiac pacemaker complaining of left lower leg pain x 2 days and reported change in mental status and increased lethargy by nursing staff. She was treated with 2 days of Keflex 500 mg PO BID without improvement. Physical exam findings are consistent with left lower leg cellulitis. In no acute distress.

 

Plan:

  1. Left lower leg cellulitis
    1. S/p Keflex 500 mg PO BID x 2 days without improvement
    2. Treat with IV Vancomycin 1 g BID – slow infusion
      1. Check trough level before 4th dose
      2. Monitor kidney function
  • Infusion via midline – 4-French 10 cm single lumen midline placed in right basilic vein following 3 attempts with <5 cc estimated blood loss.
  1. Monitor erythema and edema for worsening or improvement
  2. Monitor vital signs and mental status changes
  3. Monitor CBC daily while on antibiotic therapy for improvement of leukocytosis
  4. Transfer to hospital if worsening condition
  1. T2DM with diabetic neuropathy
    1. Continue metformin and gabapentin
    2. Continue monitoring finger-stick glucose in morning and evening
    3. Annual follow-up with endocrinologist
  2. Hyperthyroidism
    1. Last thyroid panel within normal limits
    2. Continue methimazole
    3. Monitor for clinical signs of hyperthyroidism
    4. Annual follow-up with endocrinologist
  3. PVD with chronic left lower extremity DVT
    1. Continue anticoagulation with Eliquis
    2. Monitor condition of lower extremities for coolness, increased pain, and change in pulses
    3. Vascular consult ordered for evaluation
      1. Angiogram with possible stent placement in left lower extremity as per previous vascular follow-up
    4. COPD
      1. Recently enrolled in facility’s new respiratory management program
        1. Weekly respiratory evaluations
      2. Continue nebulizers as needed
      3. Monitor for SOB, cough, fever, signs of infection
      4. Offer annual influenza vaccination
    5. Dementia with behavioral changes
      1. Monitor for worsening condition
      2. Multiple verbal altercations with other residents recently
        1. Keep in sight of nurse’s station for continuous monitoring
      3. CAD
        1. s/p permanent pacemaker placement
        2. Continue Rosuvastatin
        3. Monitor for chest pain
        4. Annual pacemaker maintenance

 

  1. Continue diabetic and heart healthy diet and monitor for problems swallowing
  2. Monitor vitals daily
  3. Alert medical staff with any acute changes in mental status or decompensation
  4. Full code
  5. No plans for discharge
    1. No next of kin listed in patient’s chart

 

 

 

History and Physical 3

 

Identifying Data:

  • Name: JW
  • Sex: Female
  • Age: 64 years
  • Date and Time: 10/13/2020, 10:00 AM
  • Location: Far Rockaway Center for Rehabilitation and Nursing
  • Source of Information: Self, patient chart

 

Chief Complaint:

Monthly check-in

 

History of Present Illness:

JW is a 64-year-old Caucasian female, former smoker (50 pack years), with a significant past medical history of asymptomatic positive HIV status (not on HAART), chronic pain due to fibromyalgia, hyperlipidemia, COPD, schizoaffective disorder (bipolar type), and spondylolysis who was seen for a monthly visit.

She has been a resident of Far Rockaway Center for Rehabilitation and Nursing (FRCRN) since March 2017 following a hospital admission to Queens Hospital Center from home due to increasing pain, numbness, and decreased range of motion bilaterally in her shoulders, chest, and upper extremities. At the time, she reported that she suffered from chronic pain for several years, which had been worsening significantly over the last three years. Repeat cardiac enzymes and an electrocardiogram were within normal limits during this evaluation, but a C-spine MRI revealed spondylolysis and peripheral stenosis at the levels of C3-C4, C4-C5, and C6-C7. As per her chart, she reported that she had been following up with a pain management provider for several years but found that the management was not working for her so she was lost to follow-up. She was admitted for evaluation at Queens Hospital Center at that time, during which she expressed interest in being admitted to a skilled nursing facility to her assigned social worker during a psychosocial evaluation due to the patient’s concerns that she could no longer care for herself due to her increasing pain, despite her claims that her significant other, who she lived with, was supportive and helped take care of her. She was discharged to FRCRN on 3/28/2017 for rehabilitation with the expectation that she would experience a significant improvement in ADLs within 6 months of admission.

Since her admission, JW has been hospitalized twice in 2018 and 2019 for chest pain and abdominal pain respectively. She was not admitted during both incidents ad a result of a negative work-up in the ED. She has been following up regularly with her virologist every 6 months and continues to not receive HAART.

Currently, JW reports that she is feeling frustrated due to restrictions on outdoor time due to recent events with other residents at the facility. She enjoys taking morning and evening walks on the facility grounds but has since been limited to outdoor time only between 7:00 AM and 6:00 PM. She reports that this limitation has left her more stressed than usual and made her consider smoking again. She otherwise has no complaints and admits that her pain is well controlled. She denies fever, chills, sore throat, chest pain, SOB, cough, irritative voiding symptoms, changes in bowel habits, or any other symptoms. She eats well, stays active by walking daily, and is compliant with her medications. She has full ADLs and IADLs. She is DNR/DNI.

 

Past Medical History:

  • Present Illnesses:
    • HIV, asymptomatic x approximately 25 years

 

  • Long-term non-progressor; viral load undetectable and CD4 count normal for the last 20 years
  • Not on HAART
  • Follows-up with virologist every 6 months; last appointment and labs on 9/28/2020
  • Fibromyalgia x 15 years
    • Pain controlled on gabapentin, Lyrica, and ibuprofen
  • Hyperlipidemia x 3 years
    • Controlled on atorvastatin
    • Last lipid panel 8/2019 – within normal limits
  • COPD x 10 years
    • Treated with albuterol sulfate nebulizers
  • Schizoaffective disorder, bipolar type – onset unknown and unavailable in chart
    • Controlled on Abilify and Mirtazapine
    • Last follow-up with psych NP 9/8/2020 via telehealth
  • Spondylolysis – diagnosed March 2017
    • No follow-up
  • Past Illnesses:
    • Denies any other past illnesses
  • Hospitalizations:
    • See HPI
    • Denies other hospitalizations; no records in patient’s chart
  • Immunizations:
    • All childhood immunizations up to date
    • Receives annual influenza vaccination
    • Refused pneumococcal vaccination
  • Screenings:
    • Vision – 7/16/2020
      • Stable cataracts without complaints
      • Corrected vision – 20/40 OD, 20/25 OS
    • Dental – 9/9/2020
      • Full upper and lower functional dentures
      • Good oral hygiene with no complaints
    • Colonoscopy 2017
      • Normal
    • Last pap and mammogram “a while ago”
      • No information in patient chart concerning gynecological follow-up

 

Past Surgical History:

JW denies any past surgeries, injuries, or transfusions

 

Medications:

  1. Albuterol sulfate 2.5 mg/5 mL nebulizer TID PRN
  2. Aripiprazole (Abilify) 10 mg PO QD
  3. Mirtazapine 15 mg PO QD

 

  1. Atorvastatin 20 mg PO QD
  2. Gabapentin (Neurontin) 100 mg PO TID
  3. Pregabalin (Lyrica) 50 mg PO QD
  4. Ibuprofen 600 mg PO Q6hours PRN

 

Allergies:

JW denies any known allergies to medications, foods, or environmental factors

 

Family History:

Family history is non-contributory.

 

Social History:

            JW is a 64-year-old Caucasian female. She was previously employed as a massage therapist but stopped working due to her chronic pain almost 10 years ago. Prior to her admission to FRCNR, JW lived in a co-op, but has since sold it. She currently has no address, which is holding up her discharge from the facility. She expresses frustration over this because she wants to leave the facility but needs to be able to get an apartment first. She also expressed interest in housing support for people living with HIV. She is a former smoker, having smoked 1 pack per day for 50 years (50 pack years). She quit at the time of her admission to FRCRN but expresses that her current stress has made her consider smoking again. She admits past, but not current, occasional marijuana use and social drinking. JW has been in a relationship with her boyfriend for 15 years and has never been married. She has had several male sex partners in the past but is not currently sexually active. She reports that she has been in menopause for 13 years. She has no children. She reports that she eats well and sleeps 5-6 hours each night. She enjoys being outside in the morning and evening and taking walks on the facility grounds.

 

Review of Systems:

General:

Denies fever, chills, night sweats, fatigue, weakness, loss of appetite, and recent weight gain or loss

Skin, hair, nails:

Denies changes in texture, excessive dryness or sweating, discolorations, pigmentations, moles/rashes, pruritus, and changes in hair distribution

Head:

Denies headache, vertigo, head trauma, unconsciousness, coma, and fracture

Eyes:

Wears glasses. Denies visual disturbances, fatigue, lacrimation, photophobia, and pruritus.

Ears:

Denies deafness, pain, discharge, tinnitus, and use of hearing aids

Nose/Sinuses:

Denies discharge, epistaxis, and obstruction

Mouth and throat:

Uses functional upper and lower dentures. Denies bleeding gums, sore tongue, sore throat, mouth ulcers, and voice changes.

Neck:

Denies localized swelling/lumps, stiffness, and decreased range of motion

Pulmonary:

Denies dyspnea, SOB, cough, wheezing, hemoptysis, cyanosis, orthopnea, and PND

Cardiovascular:

Denies chest pain, palpitations, irregular heartbeat, syncope, and known heart murmur

Gastrointestinal:

 

Denies changes in appetite, intolerance to foods, nausea and vomiting, dysphagia, pyrosis, flatulence, eructation, abdominal pain, diarrhea, change in bowel habits, hemorrhoids, constipation, rectal bleeding, and blood in stool.

Genitourinary:

Denies urinary frequency, changes in color of urine, incontinence, dysuria, nocturia, urgency, oliguria, abnormal vaginal discharge, and vaginal bleeding.

Musculoskeletal:

Reports chronic pain due to fibromyalgia that is currently well managed. Denies deformity, and arthritis

Peripheral Vascular:

Denies intermittent claudication, coldness, and color changes

Hematologic:

Denies anemia, easy bruising or bleeding, lymph node enlargement, and history of DVT/PE

Endocrine:

Denies polyuria, polydipsia, polyphagia, heat or cold intolerance, and goiter.

Nervous System:

Denies seizures, loss consciousness, sensory disturbances, ataxia, loss of strength, change in cognition/mental status/memory, and weakness

Psychiatric:

History of schizoaffective disorder. Denies feelings of depression/sadness, anhedonia, obsessions, compulsions, and visual/auditory hallucinations. She currently follows with the facility’s psychiatry NP

Physical Exam:

Vital Signs:

Blood Pressure: 140/89 (right arm, sitting)

Heart Rate: 93 beats/minute (regular)

Respiration Rate: 16 breaths/minute (nonlabored)

Temperature: 99.1 F (oral)

O2 Sat: 97% (room air)

Height: 66 inches

Weight: 210 lbs

BMI: 33.9

General Appearance:

64-year-old obese female dressed appropriately with good hygiene seen sitting up in bed. Patient’s room decorated with pictures of friends and family with multiple books and electronic devices available. A&O x 3. Calm and cooperative. She answers all questions and follows commands. In no acute distress.

Skin:

Skin is warm and moist with appropriate turgor throughout. No erythema, cyanosis, jaundice, or other discoloration noted. No concerning skin lesions or open wounds observed.

Nails:

No clubbing or signs of infection. Capillary refill <2 sec throughout.

Hair:

Hair quantity and texture unremarkable.

Head:

Normocephalic and atraumatic. Nontender to palpation throughout, without signs of alopecia, seborrhea, or lice.

Eyes:

Wearing glasses. Symmetrical OU without evidence of strabismus or ptosis. Sclera white, conjunctiva pink, and cornea clear. Visual fields full. PERRLA. EOMI without nystagmus

Visual Acuity: Not assessed.

Fundoscopy: Not assessed.

Ears:

Symmetrical and normal size. No evidence of lesions, masses, or trauma on external ears. No discharge, foreign bodies in external auditory canals AU. TMs pearly gray and intact with light reflex in appropriate position AU. Auditory acuity intact to whispered voice.

Nose:

Symmetrical without obvious masses, lesions, deformities, trauma, or discharge. Nares patent bilaterally. Nasal mucosa pink & well hydrated. No discharge noted on anterior rhinoscopy. Septum midline without lesions, deformities, injection, or perforation. No evidence of foreign bodies.

Sinuses:

Nontender to palpation and percussion over bilateral frontal and maxillary sinuses.

Mouth and Pharynx:

Lips: Pink, moist, no evidence of cyanosis or lesions.

Mucosa: Pink; well hydrated. No masses or lesions noted.

Palate: Pink, well hydrated. Palate intact without lesions, masses, or scars.

Teeth: Upper and lower functional dentures in place.

Gingiva: Pink and moist without evidence of hyperplasia, masses, lesions, erythema, or discharge.

Tongue: Pink and well papillated. No masses, lesions, or deviation noted.

Oropharynx: Well hydrated and without evidence of injection, exudates, masses, lesions, foreign bodies. Tonsils present with no evidence of injection or exudate. Uvula pink without edema or lesions.

Neck:

Trachea midline. No masses, lesions, scars, or abnormal pulsation noted. Supple, nontender to palpation. FROM. No stridor noted. Thyroid non-tender, no palpable masses, no thyromegaly.

Chest:

Symmetrical without deformities or signs of trauma. Respiration unlabored and without use of accessory muscles. Lateral : AP diameter 2:1. Non-tender to palpation.

Lungs:

Clear to auscultation bilaterally without adventitious lung sounds.

Cardiovascular:

Regular rate and rhythm. S1 and S2 present. There are no murmurs, S3, S4, splitting of heart sounds, friction rubs, or other extra sounds. Carotid pulses ae 2+ bilaterally without bruits.

Abdomen:

Flat and symmetrical without evidence of scars, striae, caput medusae or abnormal pulsations. BS present in all 4 quadrants. Tympanic to percussion throughout. Non-tender to percussion or to light/deep palpation. No evidence of organomegaly. No masses noted. No evidence of guarding or rebound tenderness. No CVAT noted bilaterally.

Genitourinary:

         Not assessed.

Rectal:

Not assessed.

Peripheral Vascular:

Extremities are normal in color, size and temperature. Pulses are 2+ bilaterally in upper and lower extremities. No bruits noted. No clubbing, cyanosis or edema noted bilaterally.

Musculoskeletal:

No swelling or deformity observed throughout. Mild tenderness to palpation in neck, chest, and along upper extremities. FROM of upper and lower extremities bilaterally. Some neck stiffness. Muscle strength 5/5 throughout.

Neurological:

Mental Status:

Alert and oriented to person, place and time. Memory and attention intact. Receptive and expressive abilities intact. Thought coherent. No dysarthria, dysphonia or aphasia noted. Follows commands. Exhibits good insight and judgment throughout interview.

Cranial Nerves:

I – Intact no anosmia.

II- Visual acuity not assessed. Visual fields by confrontation full. Fundoscopy not assessed.

III-IV-VI- PERRLA, EOM intact without nystagmus.

V- Facial sensation intact, strength good.

VII- Facial movements symmetrical and without weakness.

VIII- Hearing grossly intact to whispered voice bilaterally.

IX-X-XII- Swallowing intact. Uvula elevates midline. Tongue movement intact.

XI- Shoulder shrug intact. Sternocleidomastoid and trapezius muscles strong.

Motor/Cerebellar:

Patient observed freely ambulating around facility unassisted. Full active and passive ROM of all extremities without rigidity or spasticity. Normal muscle bulk and tone. No atrophy, tics, tremors or fasciculations. Strength equal and appropriate for age bilaterally. Gait normal with no ataxia.

Sensory:

Intact to light and sharp touch, sharp/dull, point localization, and extinction.

Reflexes:

            Not assessed.

Meningeal Signs:

No nuchal rigidity noted. Brudzinski’s and Kernig’s signs negative.

 

Labs:

  • Most recent CBC and CMP within normal limits
  • Viral load undetectable
  • CD4 count within normal limits

 

Assessment:

JW is a 64-year-old Caucasian female, former smoker (50 pack years), with a significant past medical history of asymptomatic positive HIV status (not on HAART), chronic pain due to fibromyalgia, hyperlipidemia, COPD, schizoaffective disorder (bipolar type), and spondylolysis who was seen for a monthly visit. She is currently doing well but is considering taking up smoking again due to stress. She is interested in taking steps towards getting an apartment so she can be discharged from FRCNR. In no acute distress.

 

Plan:

  1. HIV, asymptomatic long-term non-progressor
    1. Continue regular 6-month follow-up with virologist
    2. Offer pneumococcal and influenza vaccinations
  2. Fibromyalgia
    1. Continue gabapentin, Lyrica, and ibuprofen
    2. Monitor for pain management
  3. Hyperlipidemia
    1. Continue atorvastatin
    2. Monitor annual lipid panel
  4. COPD
    1. Continue albuterol sulfate nebulizers as necessary
  5. Schizoaffective disorder, bipolar type
    1. Continue Abilify and Mirtazapine
    2. Follow-up with psych NP via telehealth in 2 months or sooner as needed as per last note
  6. Spondylolysis
    1. No follow-up
    2. Monitor for headaches, limb weakness, changes in pain, loss of balance, etc.
  7. Social work to follow up with discharge planning
    1. Cleared by medicine and physical therapy
    2. Full ADLs and IADLs
    3. Application for HIV housing assistance program
    4. Discuss with patient’s significant other and aunt – next of kin
  8. Continue full diet as tolerated
  9. Smoking counseling
    1. Educated on risks of smoking and COPD, of which the patient was already aware
    2. Follow with director of nursing concerning restrictions on outdoor time for all residents secondary to incident with small group of residents and illicit substances, as that is the cause of the stress leading JW to start smoking again
    3. Patient agreeable to waiting a few days to see if anything can be done regarding the universal restrictions
  10. Advance directives in place – DNR/DNI
    1. MOLST signed and in patient’s chart
  11. Continue encouraging ambulation around the facility
  12. Monitor vitals daily
  13. Encouraged to bring up any questions and concerns with the facility staff

 

Attribution-NonCommercial-ShareAlike 4.0 International

This entry is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International license.