Daniela Arias Rodriguez

Long Term Care Rotation H&P #1  2/27/20

HPI: Mr. N 93 y/o Puerto Rican male with PMHx of COPD, BPH, open-angle glaucoma, OA of knee, mood disorder, and dementia. Prior to his admission to the skill nursing facility of Gouveneur Hospital in 2015, pt was living with his step daughter and attending an adult day care center. Pt was seen by a psychiatrist at Bellevue hospital for dysphoria and labile mood, which got aggravated since his wife for 25 years, was admitted to the skill nursing facility of Gouveneur hospital due to schizophrenia. For two years, pt was visiting  his wife at Gouveneur weekly. As per step daughter, patient was becoming  more aggressive, forgetful and more dependent on ADLs. Pt voluntarily decided to be admitted to Gouveneur hospital, which was previously suggested by his psychiatrist.

Currently, patient is doing well and is very energetic. Pt keeps himself occupied by drawing and doing puzzling games. Pt ambulates the unit in a wheelchair and uses the walker in his room. Pt receives assistance with his ADLs. He spends time with his wife during breakfast and lunch time. Initially, they were both in the same suite, but later she was placed in a separate room. There is no plan of discharge as daughter cannot take care of him at home, and pt feels emotionally better by seeing his wife daily. Today, pt complains of constant shortness of breath when lying down in bed for the past 2 weeks. Pt also reports bilateral lower leg edema x 1 week. He is on the bi-pap machine every night from 11:00pm to 8:00 am with good compliance. Denies chest pain, cough, fatigue, fever, chills, N/V/D or urinary symptoms.

Past Medical History

Present illnesses –Dementia, COPD, BPH, open-angle glaucoma, and OA of knee

Past medical illnesses –Mood disorder
Hospitalized – (detail in surgery section).

Immunizations

Colonoscopy

Past Surgical History: 

No surgery hx

 Medications:

Latanoprost 0.005% opth 1 drop both eyes at bedtime, for glaucoma.

Dorzolamine 2% opth 1 drop both eyes tib, for glaucoma.

Polyeth glycol powder 1 pack PO 1/day prn, for constipation.

Terazosin 1mg 1 cap PO at bedtime, for BPH.

Finasteride 1 tab PO 1 daily, for BPH.

Combivent Respimat 1 puff orally q 8hrs, for COPD.

Ipratropium-albuterol 0.5-2.5 mg/3ml 3ml q 8hrs prn, for COPD.

Allergies: 

No allergies

Family History:

Social History:

Mr. N is retired Puerto Rican male who used to work as construction worker. Pt was previously living w/ his step daughter. Denies history of smoking, use of alcohol or tobacco.

ROS:

Gen –Denies loss of appetite, fatigue, weight loss, fever, chills or night sweats.

Skin, hair, nails—Denies change in texture, dryness, pruritus, diaphoresis or change in hair distribution.

Head—Denies headache, vertigo, light-headedness or head trauma

Eyes—Admits poor and blurry vision. Denies photophobia, pruritis, dryness, diplopia, scotoma, halos or eyes fatigue.

Ears—Pt admits poor hearing and tinnitus bilaterally. Pt has hearing aids, but has poor adherence. Denies ear pain and discharge.

Nose/sinuses—Denies nose discharge, epistaxis or obstruction.

Mouth/throat—Denies bleeding gums, sore tongue, sore throat, mouth ulcers, or changes in voice. Unknown last dental exam.

Neck—Denies localized swelling, lumps, stiffness or decreased range of motion

Pulmonary –Admits constant SOB when lying down in bed x 2 weeks. Pt uses the bi-pap machine from 11:00pm to 8:00 am with good compliance. Denies cough, sleep apnea, hemoptysis or wheezing.

CV—Admits mild bilateral lower leg edema x 1 week. Denies chest pain, palpitations, syncope and known heart murmur.

GI—Pt uses diaper, but uses bathroom for bowel movements. Denies abdominal pain, vomiting, nausea, diarrhea, constipation, rectal bleeding, change in bowel movements or in appetite, dysphagia, jaundice, heartburn, or abnormal color stool. Unknown colonoscopy.

GU—Pt uses diapers. He is not aware of the color of his urine, hematuria or pyuria. Denies dysuria, urinary retention or polyuria. Pt is not sexually active.

Nervous— Denies seizures, paresthesia, headache, loss of consciousness, numbness, or weakness.

Musculoskeletal— admits bilateral, intermittent, non-radiating, sharp knee pain rated 5/10. Denies muscle pain, swelling, redness, deformity of muscles or joints.

Peripheral—Admits bilateral lower leg swelling. Denies intermittent claudication, coldness, varicose veins and color change.

Hematological—  Denies hx of blood transfusion, anemia, easy bruising, lymph node enlargement or Hx of DVT/PE.

Endocrine—Denies polyuria, diaphoresis, polydipsia, polyphagia, heat or cold intolerance, goiter and hirsutism.

Psychiatric— Patient has hx of mood disorder. Pt was seen by a psychiatrist prior to his admission at Gouveneur. Currently, pt has a stable mood and is not on treatment.  

VS:T 97.8F, HR 78 bpm, BP 122/76 right arm sitting, 124/80 right arm standing, RR 18, SpO2 99% room air, BMI: 30.7

No sign of orthostatic hypotension.

Physical Exam:

Gen– AOx2, no apparent distress, well-groomed and developed. Appears younger than his stated age.

Skin: warm & dry, good turgor, non-icteric, no visible lesions, scars or tattoo.

Nails: no signs of clubbing, lesions, paronychia, capillary refill <2 second.

Hair: evenly distributed and thick texture. No sign of lesion, seborrhea or lice.

Head: normocephalic with no specific facies, non-tender to palpation, no signs of swelling or trauma.

Ear: intact tympanic membrane with undisturbed cone of light bilaterally. Unremarkable auditory canal bilaterally. Weber w/o lateralization. Rinne BC> AC.

Eyes: round, nonreactive to light and accommodation bilaterally. Pink conjunctiva and non-icteric sclera. Full EOM and visual fields. Visual acuity to counting fingers. Unable to appreciate the optic disc. No signs of retinal hemorrhage or exudates.

Mouth: Pt uses dentures. Pink mucosa with no sign of thrush or lesions.

Trachea/thyroid: midline with no lymphadenopathy, non-palpable nodule or bruit. 

Lungs:  clear to auscultation. No signs of wheezing, rhonchi or rales. No signs of labored breathing. Unremarkable egophony and tactile fremitus.

Cardiac: Normal S1/S2 and RRR. No murmur, JVD or carotid bruit noticed.

Abdomen: Bowel sound present in all 4 quadrants. A reducible umbilical hernia with no signs of strangulation or incarceration. Abdomen non-tender to palpation. No signs of distention, striae, scars or palpable mass.

GU: descended testicles bilaterally, no penile lesion or discharge, no hernia. 

Rectal: prostate non tender with no masses slight enlarge. No stool in rectal vault. Negative guaiac.

Extremities: 1+ lower leg edema bilaterally which was painful to palpation. 2+ dorsalis pedis and posterior tibial pulses bilaterally. Full active/passive ROM upper and lower extremities bilaterally with crepitus in multiple joints.

Neurology: alert and oriented to person, situation and place only. Poor heel-shin and intact finger to nose test. Positive Romberg test. Unsteady gait. Pt needs the walker to ambulate. Muscle strength 4/5 in both UE and LE. Ankle, biceps and triceps reflexes 2+ bilaterally. Intact sensation to touch and vibration bilaterally. Poor proprioception in LE bilaterally. Intact cranial nerves 2-12. Unable to asses olfactory nerve. Mental status exam 20.

Assessment/plan: Mr. N 93 y/o Puerto Rican male with PMHx of COPD, BPH, open-angle glaucoma, OA of knee, mood disorder, and dementia.

1. Orthopnea: When lying in a flat position x 2 weeks not related to walking or activity. Lungs were cleared to auscultation bilaterally with no egophony and tactile fremitus. No symptoms of cough, chest pain, fever, chills or fatigue. Likely due to preexisting COPD. Order x-ray to discard pleural effusion or pneumonia. Continue combivent Respimat 1 puff orally q 8hrs, ipratropium-albuterol 3ml q 8hrs and bi-pap machine from 11:00pm to 8:00 am every night.
2. Bilateral lower leg edema: 1+ lower leg edema bilaterally experienced x 1 week. Symptom of orthopnea x 2 weeks. Probably due to preexisting COPD. Add Lasix 20 mg PO bid for 5 days. Monitor blood pressure twice/day.
3. Blurry vision: visual acuity to counting fingers. No exudate or hemorrhage on fundoscopy. Optic disc was not visualize. No eye pain, photophobia, dryness, diplopia, halos or eye fatigue. Probable adverse reaction from his glaucoma medication Latanoprost and Dorzolamine, which both have blurry vision as an adverse reaction. Check optic pressure bilaterally. Monitor patient closely to prevent any falls. Place a referral for the ophthalmologist further evaluation, alternative or discontinuing one of the medications.
4. COPD: New episodes of orthopnea and lower leg edema bilaterally. Lungs were clear to auscultation bilaterally. No chest pain, or fatigue. Continue combivent Respimat 1 puff orally q 8hrs, ipratropium-albuterol 3ml q 8hrs and bi-pap machine from 11:00pm to 8:00 am every night. Start Lasix 20 mg PO bid for 5 days.
5. Open- angle glaucoma: No eye pain, photophobia, dryness, diplopia, halos or eye fatigue. Continue Latanoprost 0.005% opth 1 drop both eyes at bedtime and Dorzolamine 2% opth 1 drop both eyes tib until examine by ophthalmologist for blurry vision.
6. BPH: no urinary retention, dysuria or other urinary symptoms. Continue Terazosin 1mg cap PO at bedtime and Finasteride 1 tab PO 1 daily. Monitor diaper for change in urine color, hematuria and urine retention. Check PSA levels and performing DRE annually.
7. Bilateral knee pain: bilateral, intermittent, non-radiating, sharp knee pain rated 5/10. Full active/passive ROM. No tenderness to palpation with crepitus bilaterally. Likely due to preexisting arthritis. Add acetaminophen 325 mg q 6 hrs as needed.
8. Mood disorder: no aggressive or agitated behavior noticed recently. Keep quality time with his wife at meals and unit activities. Continue to provide puzzling game and material for drawing.
9. Dementia: No current treatment. Monitor decline in cognitive and functional abilities.

Article Summary

Laser Trabeculoplasty for Open-Angle Glaucoma

A Report by the American Academy of Ophthalmology

• It is review done by the American Academy of Ophthalmology in 2011.
• The search was performed on the databases Cochrane Library and PubMed between June 2008 and March 2010.
• This review intended to determine the following:
• The amount of intraocular pressure (IOP) lowered by the use of laser trabeculoplasty and duration of the treatment effects.
• How effective is laser trabeculoplasty at decreasing IOP as compared to medical or surgical treatment.
• Difference in safety and treatment outcomes between the difference types of laser trabeculoplasty
• How many times laser trabeculoplasty can be repeated.
• 637 articles addressing laser trabeculoplasty were found of which 145 were included in the final analysis
• The articles were rated based on their level of evidence. Level I was assigned to systematic review and well-conducted RCT. A level II was given to case-control and cohort studies and to studies with poor randomization. A level III was assigned to case series, case report and cohort/case -control with poor quality.
• A Cochrane review published on 2008 and one RCT were given a level I evidence. RCT with small sample size, case series, non-randomized control trials and retrospective review were given a level II or III evidence.
• Significant reduction of IOP was found (>75% cases) with laser trabeculoplasty when it was used as an initial treatment in patients without any prior eye surgery.
• In one the studies, it was that argon laser trabeculoplasty had more long term efficacy as compared to initial medical treatment.
• Success of ALT at reducing IOP has evidence of I, while DLT and SLT have an evidence level of II.
• The laser trabeculoplasty SLT as similar effect to topical medication at reducing IOP with an evidence level of II
• The efficacy of DLT and SLT at lowering IOP and its related complication as similar to ALT with an evidence level I.
• In term of procedure repetition, ALT was most successful, although with an evidence level of III. Some evidences support that repeated ALT procedures within 12 months of initial treatment are more likely to receive further intervention as compared to those patients with successful procedures for than 12 months.

Journal Article

1-s2.0-S0161642011004611-main

Site Evaluation Summary

In the final site evaluation, I presented a 93 y/o male with a PHMx of COPD, BPH, open-angle glaucoma, OA of knee, mood disorder and dementia. Patient was admitted to Gouveneur in 2015 with episodes of aggravated mood, decline in functional activities and memory after his wife of 25 years was admitted to the same facility.  On physical exam, the patient was complaining of bilateral peripheral edema, dyspnea and blurry vision. Overall, I received a good feedback. I was advised to improve my assessment and plan. I was also advised to improve on developing differential and alternative hypotheses as well as elaborating more on active complaints. I presented a review done by the American Academy of Ophthalmology on the use of laser trabeculoplasty for open-angle glaucoma. Dr. Davidson advised me to select more recent studies, so that it can be more applicable to current practice. In terms of the pharmacology assignment, I still need to improve this area. I need to make better connections between adverse effects, monitoring, and indications, so that is easier to remember.

Typhon Report

Typhon RT2

End of Rotation Self-reflection: RT-2 Long Term Care

 What was a memorable patient or experience that I’ll carry with me? In this rotation I met patients with interesting stories, but there was a 106 y/o female who I will always remember. Despite her advanced age and multiple medical problems, she kept herself very active in the facility. She ambulates in a wheelchair, which she pushes with her feet. She eats, brushes her teeth and hair by herself. One thing that surprised me the most was her ability to recall. She still remembers when she first arrived in the United States, her past occupation and for how long she worked. She is completely aware of her medical problems. When I first met her, I told her my name and challenged her to remember it the next morning. When I came to her room the next day, she told me “good morning daniela.” I was amazed by this lady. After I met her, I visited her during every shift. She was very happy every time I stopped by her room. She is the vivid example that aging does not always take your memories and energy away. 

 Types of patients you found challenging in this rotation and what you learned about dealing with them. Elderly patients are challenging due to their multiple comorbidities, medications and fall risk. If patients are bed-bound, even more challenging due to possible development of pressure ulcers and numerous complications that can come with them. However, in this rotation, I found a new type of patient that can be more challenging than elderlies. I saw a few patients with dementia with behavioral disturbances.  These patients were constantly yelling and screaming, although, they did not represent a threat to the staff or to other patients. It was challenging to do a physical exam without getting them agitated. Assessing for pain, discomfort or any other symptom was very unreliable. As expected, these patients were not very cooperative with the staff sometimes. I learned that with these patients it is important to give them some time to relax and calm down. Performing the assessment or physical exam at a later time might be more appropriate. I found that establishing a basic conversation about “how was your breakfast” or “how did you sleep last night” can be helpful to distract the patient. 

What did you learn about yourself during this 5-week rotation?One thing I learned about myself is that I am an old soul trapped in a young body. Generally, young people are not too excited to talk or interact with elderlies. As far as me, I really enjoyed talking and taking care of geriatric patients. During the didactic year, we were told that among all the specialties the most rewarding one was geriatrics. That was so true. They are very grateful and appreciate the minimal help you can provide. It is much easier to build a relationship with geriatric patients and promote adherence to treatment. I am not too sure if I will see myself in geriatrics, but I don’t eliminate that possibility. 

 What do you want to improve on for the following rotations? What is your action plan to accomplish that? Two areas that I need to improve are fundoscopy and neuro exam. I noticed that I still have difficulty finding the optic disc and performing neuro exams. Assessing the retina and optic disc is very important in diabetic patients as well the neuro/ mini-mental status exams in patients with dementia. In order to improve these skills, I have to practice fundoscopy more often at home and at my next rotations. Watching videos on the mini-mental/neuro exams from our didactic year along with  practicing neuro/mini-mental exams more often, will certainly be helpful to improve these skills.