Pre-Class Assignment for Wk 2, Session #1 (4/13/20)

Following are two HPIs with preceding information.  Please review the document I sent earlier “On writing an effective H&P for a patient in a Long-Term Care Facility”.  Now I want you to take on the role that I usually have:

• Read these two HPIs and note what’s
  • Good
  • Missing
  • Needs better order
  • Needs to be expanded
• Write a brief summary of the feedback you would give this student

We’ll discuss these at the start of our first session and I’ll ask you to turn them in afterwards.

PATIENT 1

Name: O. A.

DOB: 5/18/1946

Date/time: 3/25/19 @ 12: 25 pm

Location: MTNC

Information source: patient/transfer records

CC: Left hip pain after fall x 1 day

History of Present Illness:

72 y/o female with a PMHx of HTN, HLD, CAD s/p CABG, GERD was admitted to NYPQ from 3/17/19 to 3/20/19 with chief complaint of left hip pain s/p mechanical fall. Pt slipped while going down stairs in her house. Admits to having pain in the left hip that radiates to her left groin with a severity of 6/10.  Patient describes the pain as being sharp in nature and impairs ambulation.  Patient denies any chest pain, SOB, syncope, dizziness, diaphoresis, headache, palpitations. Pt deemed stable and transferred to MTC for restorative rehabilitation.

Generally not a bad start to an HPI. It has a lot of quality information in here and the order is appropriate and really concise. I would try to focus on the following:

• Home life at the time of injury (care giver, husband)
• How long after the injury did she get medical tx? Any self tx?
• What did they do for her for the three days she was in the hospital?
  • Labs, imaging, PT/OT, consults
• What were her baseline ADLs compared to her current daily activities
• Is this patient reliable?
• ROS: numbness, tingling, popping, clicking, urine/bowel incontinence or retention
• How are you able to state this patient is stable without knowing what was completed inpatient

_________________________________________

PATIENT 2

Identification:

• Name: A.W
• Sex: Male
• Race: Caucasian
• Nationality:
• Age: 82
• Marital Status: Not married
• Address:
• Religion:

Informant:

• Source of hx: Self/Transfer Records
• Competency: Semi-reliable Say why

Referral Source:

CC:  “ Pain on right side of my body x1 day”

HPI: 82 y/o male, with significant pmhx of depression, hypothyroidism, and dementia, fell in his house X1 day ago and is now experiencing pain on the right side of his body. When he awoke he did not recall his fall. He told his PC who drove him to the ER in NYPQ, where he was admitted from 1/8/19 to 1/10/19 and was diagnosed with a “broken right clavicle bone”. No cast, or support was placed to help the healing process, patient claims “doctors want it to heal on its own”. Patient claims he was transferred because “doctors believe he will be able to rest here”. Patient has extensive bruising and pain on the right side of the body, and when he turns his head to his right, otherwise, keeps saying “I don’t really fall that often”. Medical records from NYPQ show fracture of the spinous process of the lumbar vertebra due to repeated falls, however right and left clavicles are intact and unfractured. Patient is alert and oriented to person, but not place or time, lives on his own, has depression, major memory defects, a family history of Alzheimer’s and dementia.

This one is not as organized but there is more information presented. The chart review from the inpatient hospitalization was a lot more thorough than the previous one. However the HPI is disorganized and has added information that is not needed in the paragraph.

• His A&O status is not necessary here
• Does not need family hx of alzheimers here

There needs to be more questioning about his pain, how bad is it, does it radiate, ect.

How many times has he fallen, when was the first fall.

Does he have a care giver at all?

Facility

Where is the patient right now

When they were seen

Reliable sources from agencies

___________________________________________________________________________________________________

Post Class Assignment for Long Term Care

What is frailty and how is it defined?

Frailty is most likely an age-related condition that combines primarily physiological decline and some psychological health decline. Older patients usually (not always) have multiple symptoms including fatigue, difficulty ambulating, weight loss, complex medical history and decreased tolerance to medical/surgical care. These issues can significantly affect the well-being of patients and adequate evaluation and management is needed. I

What are the features of frailty? 

Frail patients often include the following features:

• Exhaustion
• Weakness
• Weight loss
• Slow walking speed
• Decreased physical activity
• Accumulation of illnesses
• Functional/cognitive decline

What assessment tools are available to determine whether someone is frail or at risk for frailty?

FRAIL scale:

Fatigue	Felt fatigued most or all of time	Yes=1 No=0
Resistance	Difficulty climbing stairs	Yes=1 No=0
Ambulation	Difficulty walking one blood	Yes=1 No=0
Illnesses	Any illnesses (HTN, DM, Cancer, ect)	Yes=1 No=0
Loss of Weight	Loss >5% of weight in past year	Yes=1 No=0

Score 0-5. 1-2 pre frail. 3-5 frail. A score of 0 is considered robust health status.

Study of Osteoporotic Fractures: Need 2 of the following components:

• Weight loss of 5% in the past year
• Inability to rise from chair 5 times without use of arms
• A “no” response to the question “Do you feel full of energy?”

Edmonson Frail Scale:

• 14 questions that covers a range of topics from cognition, general health, function and nutrition

Clinical Frailty Scale:

• Rapid screening tool scored between 1-7 based on self-report of comorbidities and ADLs

Why is it important to identify these patients?

Frail patients need to be identified to hopefully better improve their quality of life. Also by providing these patients with proper treatment they might be able to avoid costly medical treatments later. It is important to point out that prevention is better than reaction in patients with frailty. By preventing the fatigue, weight loss and other symptoms patients are less likely to put increased strain on the healthcare system.

Which factors are potentially treatable to reverse frailty or prevent it?

A lot of the factors contributing to frailty are reversible. Chiefly, establishing a diet plan would help reverse the decreased BMI and possibly decrease fatigue and may help curb chronic illnesses such as diabetes and hypertension. The NIH has sample menus for elderly to help maintain healthy eating habits.

https://www.nia.nih.gov/health/sample-menus-healthy-eating-older-adults

Another way to reverse some of the complications of frailty is to work on ambulation with PT and OT. By providing patients with necessary rehabilitation or just occupational training they can better their ADLs and even IADLs. In addition, this could help with climbing stairs, going for longer walks or participating in sporting events that the patient finds interesting.

Mental health counseling may also be beneficial. By speaking to a mental health professional elder patients may be able to manage their anxiety or depression.

It is important to point out that each patient will have different goals of care. Providers and patients need to have an open line of communication in regard to the patient’s individual priorities.