Sample H&P:

Location: Far Rockaway Nursing Home (FRNH)

Date & Time: 1/22/21, 11:30 AM

Patient Name: “JZ”

DOB: 1/13/38 (Age 82)

Sex: Male

Race: African American

Religion: Protestant

Source of Info: Self (reliable) and EMR

Referral: None

Mode of Transport: N/A

C/C: “Tired” x 1 week

HPI:

JZ is an 82 y/o AA M with PMHx GERD, unspecified arrhythmia with implanted cardiac pacemaker since 2017, CAD, DM, HLD, HTN, intermittent constipation, and COPD since former smoker of 45 years, quit 15 years ago. JZ is ambulatory with rolling walker and requires assistance with ADL’s, bathing and dressing, adult diapers, and IADL’s. Baseline functional urinary and fecal incontinence due to limited mobility and repositioning managed with bedside urinal and diaper. JZ is a resident of FRNH since 2016.

As of Weds 1/20/21, nursing staff reported diminished appetite, not eating or drinking fluids, fatigue, and overnight urine output. That day pt became febrile up to 100*F oral temp with mild cramping suprapubic pain. Staff obtained EKG, CBC, CMP, and Foley catheter placed, and >1200 mL cloudy yellow urine collected. UA positive for nitrites, leuk est, RBC and WBC’s. CBC significant for leukocytosis to 18k.

Pt ordered NPO with continuous D5 ½ NS IV 60 mL/hr x 3 days, advance liquids and soft solids as tolerated. Vancomycin IV 1500 mg loading dose then 750 mg Q daily x 7 days, and Zosyn IV 3.375 g loading dose then 2.25 g Q daily x 7 days. Vanco trough to be obtained tonight or tomorrow, prior to 4th dose tomorrow.

Overnight nursing staff report that pt became SOB last night while getting ready for bed. O2 sat was 98% ORA. Repeat EKG and bedside AP CXR obtained. EKG showed regular paced rhythm. Radiologist CXR impression pending.

Today: This morning pt encountered lying in bed, somnolent but rousable to verbal stimulus. A/O x 3, reliable, but only speaking in slow, short phrases. Slow response time to questions. Pt reports mild lower abd pain, continuous and cramping, and mild intermittent nausea x 3 days. Denies vomit or diarrhea. Reports poor appetite, but tolerates PO medication and clear liquids throughout the day. Pt reports last formed BM 3 days ago, denies pain or blood. Denies any BM since. Pt also reports fatigue and dizziness, but denies headache, vertigo, or focal neruo sx. Denies CP or SOB.

Current Medications, Indication, Last Dose:

• A&D (Vits A & D) topical ointment applied 2 – 3 times daily to legs b/l; indication dry skin; last application this morning.
• Amlodipine 10 mg PO tab, once daily; indication HTN; last dose this morning.
• Ascorbic acid 500 mg PO tab; indication nutritional supplementation; last dose this morning.
• ASA 81 mg PO chewable tab once daily; indication CAD; last dose this morning.
• Bisocadyl 10 mg rectal suppository; indication constipation; last administered yesterday.
• Dextrose-NaCl Soln 5-o.45% 60 ml/hr IV every shift x 3 days; indication sepsis; currently receiving.
• Fleet enema 7-19 gm/118 ml (Sodium Phosphates) 1 applicator-full rectally if no relief from bisocadyl suppository; indication constipation; last application last week.
• Lisinopril 5 mg PO tab once daily; indication HTN; last dose given this morning.
• Metoprolol tartate 12.5 mg PO tab BID; indication HTN; last dose given this morning.
• Multivitamin PO tablet once daily; indication supplementation; last dose given this morning.
• Vancomycin HCL soln 750 mg IV once daily x 7 days; indication sepsis; last dose currently administered.
• Zosyn (Piperacillin Sod – Tazobactam Sod) soln 2-0.25 gram IV Q 12 hrs x 7 days; indication sepsis; last dose given this morning.

Allergies: NKDA

PMHx:

• HTN
• Cardiac Arrhythmia, unspecified
• Sinus Node dysfunction, unspecified
• GERD without esophagitis
• Unspecified essential primary HTN
• Constipation, intermittent
• COPD without exacerbation
• Last routine cardiology consult 11/17/20, normal.
• Up to date on vaccinations. First dose of Pfizer COVID vaccine given 1/5/21, no sequelae.
• Status: Full code. No DNR/DNI.

PSHx:

• Cardiac pacemaker implantation, 2017 for arrhythmia 2/2 sinus node dysfunction, no sequelae.

FamHx: Noncontributory. Pt denies knowledge of significant family medical history.

SocHx: JZ is a single, never married, resident of FRNH x 4.5 year. Denies current etoh/tobacco/illicit drug use. Previous smoker of 45 pk-yrs, quit 15 years ago. Lives in dorm with 2 roommates. Denies any family or friends. Social life limited to nursing staff and other residents of nursing home. Reports minimal exercise tolerance, ambulatory with assistance and rolling walker. Reports difficulty physically performing ADL’s and IADL’s without assistance. No known COVID contacts. No other roommates sick. No recent travel.

ROS:

Constitutional: Reports fatigue and recent fever. Denies malaise, weight change, chills, or night sweats.

ENT/Mouth: Denies hearing changes, ear pain, nasal congestion, sinus pain, hoarseness, sore throat, rhinorrhea, or swallowing difficulty.

Eyes: Denies blurry vision, eye pain, swelling, redness, foreign body, or discharge.

Cardiovascular: Reports recent SOB and hx arrhythmias. Denies CP, PND, or DOE. Denies orthopnea, claudication, edema, or palpitations.

Respiratory: Previous smoker. Reports DOE. Denies cough, sputum, wheezing, smoke exposure, dyspnea, or hx asthma.

Gastrointestinal: Reports mild lower abd cramping pain and nausea. Reports hx intermittent constipation & GERD. Last formed BM 3 days ago. Denies vomiting, diarrhea, or fecal incontinence. Denies heartburn, anorexia, dysphagia, hematochezia, melena, flatulence, or jaundice.

Genitourinary: Reports oliguria and pyuria. Denies dysuria, hematuria, urinary incontinence, urgency, dribbling, or flank pain. Denies lesions or urethral discharge.

Musculoskeletal: Denies arthralgias, myalgias, joint swelling, joint stiffness, back pain, neck pain, or hx of serious injury.

Skin: Reports frequent dry skin. Denies lesions, pruritis, hair changes, or nail changes.

Neuro: Denies weakness, numbness, paresthesias, loss of consciousness, syncope, dizziness, headache, coordination changes, or recent falls.

Psych: Denies depression, anxiety, panic, insomnia, personality changes, delusions, or rumination. Denies suicidal ideation, homicidal ideation, or auditory or visual hallucinations. Denies eating disorder.

Heme/Lymph: Denies easy bruising or bleeding. Denies transfusions history. Denies lymphadenopathy

Endocrine: Denies polyuria, polydipsia, or polyphagia. Denies tremors, palpitations, agitation, changes to energy or activity level, sleep, or temperature intolerance.

Physical Exam:

General: Pt is somnolent in bed with 2 pillows but awakes spontaneously. Pt is A/O x 3, NAD, offers minimal responses to questions. Appears stated age. Appropriately dressed. Good hygiene.

V/S: BP 128/78, HR 60, Resp 20, O2 Sat 98% ORA, Temp 99.0*F, Ht 74”, Wt 160, BMI 20.5

Head: Normocephalic. Normal hair pattern. Atraumatic.

Eyes: PERRLA, EOM’s intact. No gross pathology noted on fundoscopy.

ENT: Ear symmetrical, no lesions. Otoscopy grossly normal. No lesions, cerumen, discharge, FB. TM pearly, cone of light intact, normal position bilateral. Nares patent. Nasal mucosa pink and moist, septum midline, no discharge, epistaxis, or FB noted. Oral mucosa pink and dry, no lesions noted. No perioral cyanosis. Good dentition. No loose teeth noted. No abscesses, swelling, bleeding, or discharge noted. No tonsillar or pharyngeal erythema or exudates.

Neck: Trachea midline. No JVD. No cervical lymphadenopathy.

Chest/Lungs: Palpable, nontender implanted pacemaker, 3×4 cm, present over superior-lateral left chest. Well healed scar, horizontal, 5 cm length, 3 cm below lateral 1/3^rd left scapula, no redness or swelling noted. Barrel chested habitus, tympanic to percussion throughout. Normal work of breathing, symmetrical chest rise, no accessory muscle use or contractions noted. No wheezes, or rhonchi noted. No tactile fremitus or egophony.

Heart: RRR. S1, S2 present. No murmurs, gallops, or rubs appreciated. No thrills.

ABD: Nondistended, soft, no discoloration or varicosities noted. Suprapubic tenderness on deep palpation, no guarding or rebound tenderness. BS diminished x 4. Dull to percussion throughout. No fluid wave. No palpable liver or spleen. No CVAT.

GU: Adult diaper, clean, dry. Foley catheter present, well placed, no bleeding, discharge, or leakage noted. No lesions noted. DRE not performed.

Skin: Warm, dry and thin. Poor turgor and tenting over extensor side of elbows and forearms. No cyanosis, jaundice, erythema or lesions noted. No tattoos.

Musculoskeletal: Limited examination seated in bed reveals 4/5 strength UE b/l and 4/5 strength LE b/l. No crepitus, swelling, or tenderness over joints noted. Gait not assessed. DTR’s not assessed.

Extremities: Left UE antecubital IV catheter in place with IV D5 ½ NS and Vanco plus Zosyn being administered. No erythema, swelling, or bleeding at IV site. No clubbing, cyanosis or edema. Distal pulses intact 1+ b/l UE and LE.

Neuro: CN II-XII grossly intact. Sensation to light touch intact all 4 extremities. Heel to shin test normal. Finger to nose test normal. No asterixis.

MMSE: 20 (difficulty spelling “world” backwards, recalling 3 items, and drawing pentagons).

Last Set of Labs:

CMP (1/20/21):

Gluc     81

BUN     23

Crt       1.19 (H)

eGFR AA >59

eGFR non-AA >59

BUN/Crt Ratio 19.33

Na        139

K          5.1

Cl         99

CO2     38 (H)

Ca        9.0

Prot Total 6.2

Alb       3.7

Glob    2.5

A/G Rat 1.48

Bili Total 1.0

Alk Phos 66

AST      22

ALT      28

CBC w/diff (1/21/21):

WBC    18.2 (H)

RBC      4.20

Hgb      13.8

Hct       42.1

MCV    102

MCH    32.1

MCHC 32.3

RDW    11.1

Pts       210

Neu     63 (H)

Lymph 30

Mono 5

Eos      2

Basos   1

ANC     6.8

UA (1/20/21):

Color: cloudy yellow

S.G.:     1.051

pH:      6.1

Gluc:    Negative

Bili:      Trace

Ket:      Negative

Blood: Trace

Prot:    Large

Nitrite: Positive

Leuk Est: Large

Imaging Studies:

AP Chest XR (1/21/21): results pending as of 1/22/21.

DDx: UTI, pyelonephritis, BPH, urinary retention 2/2 constipation, HAP PNA vs. COPD exacerbation

Assessment/Plan:

JZ is an 82 y/o AA male on Day 3 of NPO, fluid resuscitation, Vanco, Zosy, for clinical sepsis 2/2 urinary tract infection presents with mild lower abd pain, nausea and fatigue. Clinical picture complicated by hx of COPD and baseline DOE. Pt tolerating clear liquids and PO medication.

• Repeat V/S, including BSL and O2 saturation, Q 6 hrs. Monitor for fever, hypoxia, and hemodynamic stability.
• Continue with Vanco and Zosyn as directed. Obtain Vanco trough level tomorrow AM before 4^th Monitor for adverse reactions to abx.
• Continue with IV D5 ½ NS and clear liquids ad lib.
• Monitor I/O and Foley catheter placement today. Trial d/c Foley tomorrow AM and monitor 24 hr urine output.
• Monitor for BM. Give ducolax or enema if no BM by tomorrow PM.
• Continue routine daily PO medication as tolerated.
• Advance diet to soft foods tomorrow AM.
• Repeat CBC and CMP tomorrow AM to monitor leukocytosis and electrolytes.
• Call attending in event of:
  • Fever > 101*F refractory to Tylenol 600 mg PO Q 6 hrs PRN
  • New or worsening rashes, wheels, blisters, or erythema
  • Tachycardia > 110,
  • Hypoxia < 93%,
  • Dyspnea or tachypnea > 30’
  • Agitation, combativeness, or Sx of delirium
  • Syncopy, LOC, or unrousable
  • Gross hematuria or worsening pyuria
  • Abd distention or severe abd discomfort.

Journal Article:

Site Eval Presentation Summary:

As this was my last rotation, I felt very confident in my ability to deliver my cases verbally and in writing. The article I presented was a systematic review of the effectiveness of various screening methods for non-ventilator healthcare-associated pneumonia (NVHAP) among inpatient populations in LTC and SNF settings. I found this article to be appropriate as is related to my first case presentation of a LTC resident with a clinical HAP diagnosis and empirical antibiotic treatment less than one week after his first Pfizer COVID vaccination. One surprising aspect of the systematic review found that there was a strong correlation between oral hygiene and HAP.

Overall I feel that my ability to parse out pertinent information from the history, physical exam, and labs has improved dramatically over the last year. I think it is a appropriate to finds myself completing my clinical year in a LTC setting, as I must call upon a wide breadth of clinical knowledge pertaining to pathologies, medications, and special considerations in geriatric and special needs populations.

Typhon Totals:

LTC Typhon Totals

Self-Reflection:

My five weeks at Far Rockaway Nursing Home presented with numerous unique considerations that challenged my original notions about geriatric populations and LTC in general. This particular site had, according to the case manager, a “young” population compared to most facilities. This is because Far Rockaway Nursing Home also serves as a safety net facility for psychiatric and behavioral health populations as well as geriatric and hospice patients. This made for an interesting mix of different pathologies, age groups, and considerations when reconciling medications and evaluating patients week-by-week. There were also special concerns for the safety or residents as well as other healthcare staff. Patients presented with varying degrees of dementia, delirium, and altered mental status. Among these patients, there were also varying degrees of level of activity and mobility. While one patient may present as a fall risk, their roommate or neighbor may be at risk of combativeness or elopement from the facility.

Seeing many of the same patients over the course of 5 weeks allowed for a greater appreciation of the arc of a patient’s baseline in terms of ADL/IADL’s, mobility or activity level, as well as cognition and demeanor. While I never directly interacted with family members or healthcare proxies myself, I became acutely aware of how important communication with appropriate third parties can be in discussing overall health status, course of care for acute issues, and advanced directives (DNR/DNI). Difficult conversations were more numerous in this rotation than others I’ve encountered so far.

I also came to appreciate how important well-trained and professional nursing staff are in managing patients around the clock. Professionalism and communication are of the utmost importance in delivering continuity of care in residential facilities, even one as relatively small as 100 patients.