H&P

Identifying Data:

Full Name: Mr. A.M.

Address: Skyway Men’s Shelter-Jamaica, NY

DOB: 10/18/1970

Date & Time: December 6, 2020

Location: Far Rockaway Nursing and Rehabilitation

Religion: Unknown

Source of Information: Self

Source of Referral: Self

Mode of Transport: Ambulette

Reliability: Reliable (self)

 

Chief Complaint: New Admission

 

HPI:

51 year-old undomiciled Caucasian male previously residing in the Skyway Men’s Shelter with past medical history of multiple sclerosis, drug abuse (cocaine and marijuana) and major depressive disorder presents to nursing home for extensive length of stay after being struck by a taxi cab on 11/18/20. He was admitted to Queens Hospital Center that day where he had open reduction internal fixation of fractures of tibia and fibula. He had subsequent debridement surgeries for infection on 11/25 and 11/27 and skin graft from left posterior calf to left anterior pretibial area.  He is being evaluated for lower left leg care, occupational therapy and physical therapy at Far Rockaway Center for Nursing and Rehabilitation (FRCRN).

He has significant history of homelessness and drug abuse (cocaine and marijuana) which he admits to using prior to the accident. He has been sober since the incident. He currently resides at Skyway Men’s Shelter and has no immediate family in the area. He states that he was ambulatory prior to injury and had no physical limitations.

Today he states the his leg is slightly painful and feels that he is getting stronger.  He has no other complaints at this time but is eager to start his PT/OT and “feels ready to get my life together.” He states that the orthopedic surgeon told him not to bare any weight on the left leg and to keep it elevated at night. He is currently using a wheelchair to move around with the use of his right foot and hands. He denies numbness, tingling, paralysis, fever, chills, SOB, chest pain, abdominal pain, dysuria.

 

Past Medical History:

Multiple sclerosis:

• Unknown date of diagnosis
• Compliant with prednisone tab 5mg daily

Major Depressive Disorder:

–  Unknown date of diagnosis

– Started on Fluoxetine 20mg at night

 

Hospitalizations: Denies previous admissions

 

Immunizations:

All childhood immunizations up to date

Annual flu shot current

States he has interest in receiving COVID vaccine 6Jan21

 

Past Surgical History:

Denies any past surgeries, injuries, or transfusions

 

Medications:

prednisone tab 5mg

Fluoxetine 20mg

 

Allergies:

NKDA, food allergies or environmental

 

Family History:

Mother-deceased with PMH of DM Type II and HTN

 

Social History:

20. M. is a 51 year-old Caucasian male who was previously employed at local grocery stores and as food delivery worker. He is currently unemployed and undomiciled. He has no immediate family and states that he has no extended family. He has been in and out of homeless shelters for the past 15 years and currently resides at Skyway Men’s Shelter. He admits to tobacco use but is vague with amount or length of time. He admits to using other illicit drugs including cocaine and marijuana but has not used since his accident 11/18/20. He is single, never married and is no currently in a sexual relationship. He denies any sleep issues and receives income from “welfare” and the government.

 

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: Denies visual disturbances, fatigue, lacrimation, photophobia, and pruritus, glasses or contacts

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, 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: Admits to occasional left leg pain. See HPI. 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 major depressive disorder. See HPI. Denies feelings of depression/sadness, anhedonia, obsessions, compulsions, and visual/auditory hallucinations.

 

Physical Exam:

Vital Signs:

Blood Pressure: 132/80

Heart Rate: 82 BPM

Respiration Rate: 16 RPM

Temperature: 97.1 F

O₂ Sat: 98% RA

Height: 70 inches

Weight: 172 lbs

BMI: 30.5

 

General Appearance: 51 y/o Caucasian male NAD well dressed and groomed. A&OxIII. No evidence of tremor or shake.

Skin: Color and temperature adequate. No cyanosis mottling or jaundice. Capillary refill less than 2 seconds.

Nails: No clubbing or cyanosis . Capillary refill <2 sec throughout.

Hair: Evenly distributed. .

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, Visual fields full. PERRL. EOMI without nystagmus. Visual Acuity: Not assessed. Fundoscopy: Not assessed.

Ears: Symmetrical. No evidence of lesions, masses, or trauma on external ears. No discharge, foreign bodies in external auditory canals AU. TMs pearly gray with all landmarks visible.

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: Teeth intact. Tongue, uvula midline. No PND. Tonsils +2.

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, friction rubs, skips.

Abdomen: Rounded abdomen and symmetrical without evidence of scars, or abnormal pulsations. BS present in all 4 quadrants. Tympany heard throughout. Non-tender to percussion or to light/deep palpation. No palpable organomegaly. No masses noted. No general tenderness, guarding or rebound tenderness. No CVAT noted.

Genitourinary: Deferred

Rectal: Deferred

Peripheral Vascular: Unable to assess pulses in left foot due to CAM boot. Pulses are 2+ bilaterally in upper extremities. No bruits noted. No clubbing, cyanosis.

Musculoskeletal: Noted left leg in a CAM boot. Toes exposed with good cap refill and sensation. No evidence of edema or discharge. No odor. No tenderness to palpation over digits of the feet. FROM of upper extremities bilaterally. Muscle strength 5/5 on right leg and upper extremities. Not assessed on left leg.

Orthopedic Note: 6cm surgical incision noted on anterior aspect of left tibia. Noted skin graph over calf posteriorly, healing well.

Mental Status: Alert and oriented to person, place and time. Memory and attention intact. Receptive and expressive abilities intact. Thought coherent.

Cranial Nerves: Grossly intact II-XII.

Motor/Cerebellar: Patient observed freely ambulating around facility unassisted. Normal muscle bulk and tone were observed with the exception of left lower leg due to CAM boot . No atrophy, tics, tremors or fasciculations. Gait no assessed due to use of wheelchair.

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

Reflexes: DTRs grossly intact +2

Labs:

POC glucose= 108 

Assessment:

51 year old Caucasian male with PMH of multiple sclerosis and major depressive disorder s/p motor vehicle accident with fractures of tibia and fibula and ORIF with subsequent skin infection and skin graft is evaluated at Far Rockaway Center for Nursing and Rehabilitation for new admission. Patient will be evaluated for physical and occupational therapy for left leg including ambulation and ADLs/IADLs. Reports of previous admissions.

Plan:

1. Orthopedic surgical repair left Tibia/Fibula – Continue physical therapy and occupational therapy as directed by the OT/PT office.
   21. F/u orthopedic eval 6Jan21.
2. Multiple Sclerosis – Continue prednisone 5mg PO daily. Neurology consult pending. Unknown reason as to why the patient is taking prednisone but neuro consult is pending.
3. Major depressive Disorder- Continue Fluoxetine 20mg PO qhs. Psych evaluation 21Dec2020 via telemedicine
4. Labs obtained: CBC, CMP, LFT, lipid panel, UA. COVID PCR
5. Social work to be seen for initial evaluation and follow up with Skyway Men’s Shelter center for updated medical record. Social work will evaluate ADLs and IADLs and discuss next of kin.
6. Start heart healthy diet and low salt (DASH) diet
7. Advance directives in place – Full Code
8. Continue encouraging movement around the facility with the use of wheelchair
9. Monitor vitals daily
10. Any new issues or concerns need to brought to the attention of the nurse, PA/NP or social worker.

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Typhon:

LTC Typhon

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Article:

Infectious Disease in the Nursing Home

I chose this article because it provided a great review on how nursing homes and long term care facilities are used for research. The article mentioned common infectious diseases that plague nursing homes but also describe diseases that are inherent to long term care facilities like B and T cell function. The articles mentions the need to conduct research for patients with who reside in long term care facilities, however a lot of the patients are not willing to fully participate or may have mortality rates that curve and skew the data. This research article shows a conceptual model to help nursing homes participate in research, which in-turn provides a better outcome for patients and care givers. Lastly, the article speaks on the need for surveillance of infectious disease outcomes. The research is easier to some extent because all of the patients are centrally located and the patients themselves provide a close cohort for easier access.

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Site Evaluation:

My site evaluations were extremely productive. Dr. Davidson address some much needed changes to my H&P and really focused on how a long term care/geriatric documentation is supposed to be. Note writing in a long term care facility is at the cornerstone for healthcare and provides a very important story to better patient’s outcomes. An important point that Dr. Davidson mentioned included in the assessment of the patient is the reason for admission and to mention this because of a medical billing point of view. There were some discrepancies within my H&Ps because I would often use a template to write my notes. These templates often are redundant and some of the items are repetitive.

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Summary:

Long term care rotation brought a lot of important aspects to medicine. The approach of a geriatric patient is different than that of a routine patient or a patient in the emergency room. The HPI within the H&P or focused note needs to provide more detail than a typical note seen in an outpatient setting or emergency room. The HPI needs to include a brief synapse of why the patient was sent to the nursing home, what was the patients baseline before the admission and other specifics that are tailored to the patient. These steps need to follow throughout the whole H&P and line up with the assessment and plan. It is necessary to keep these specific details in the H&P because of medical billing issues.

Another important aspect about taking care of long term care patients especially the elderly is the advance directives. The PA that I shadowed made this a necessary and crucial point of providing care to patients. If a patient has an advance directive and is DNR/DNI/DNH then the necessary level of care is still obtained but may not be to the level of having to intubate or resuscitate or leave the long term care facility. The PA that oversaw my clinical hours made sure that I knew each patients “code” status and we tailored our options of treatment based on that, especially in the acute setting.

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