Term 3 Sample Write-up #8

FCM Sample Write-Up #8
Term 3
Sample B

ID/CC:

Ms. H is a 57 y/o woman with a hx of COPD, diabetes, CKD, and a 42 pack year smoking hx who presented with a subacute and progressively worsening productive cough and SOB.

HPI:

Ms. H reports that she started coughing approximately 1.5 months ago and it has progressively gotten worse. It had gotten to the point where she was coughing every 2 minutes, she could no longer sleep, and she was feeling SOB. She reports that it was a productive cough, producing green sputum and a fever that started in the final days before she was admitted to the hospital on Sunday. She also reports nausea and one episode of post-tussive emesis. She denies hemoptysis. She reports that she also felt lightheaded, had a sore throat attributed to her cough, rhinorrhea, headache, cervical lymphadenopathy, constipation, increased urinary frequency and associated urinary incontinence, and abdominal cramps. She has a history of orthopnea and paroxysmal nocturnal dyspnea and reports that it was getting worse during this period. She also reports swelling in her legs and abdomen and associated ‘tightness’ in her legs, leading to a hard time walking. She also reports a focal, substernal chest pain that radiated toward the upper, middle of her back and her sides. When she felt the chest pain, she was diaphoretic and had no associated SOB. She reports the pain was worse with coughing. She was finally brought in to the ER by her son when she could no longer sleep and was admitted from there.

Ms. H has a history of non-O2 dependent COPD with 1-2 exacerbations per year that do not require intubations. She reports having a tiotropium inhaler that she uses only occasionally and an albuterol inhaler she uses several times a week. She does not report using a steroid inhaler. She has a 42 pack year smoking history. She has not been smoking for the past 2 weeks due to her symptom severity. She has no known history of CHF.

Hospital Course

Ms. H was hospitalized on Sunday and was given furosemide at the beginning of her hospital stay. She has nasopharyngeal cultures pending and is currently on azithromycin and ceftriaxone. While in the hospital she is also taking Lisinopril, prednisone, a stool softener, enoxaparin, and insulin as needed.

During our interview, her blood sugar started at 180 and ended at 230, which she attributed to her breakfast. Ms. H’s had reported feeling constipated thus far, but she finally had a bowel movement last night. She reports that she had an echocardiogram that appeared “okay” and she is awaiting results on her pulmonary CT scan.

PMH:

Medical Problems

• COPD—See HPI
• Diabetes
  • Diagnosed in 1999
  • Controlled with both long acting and short acting insulin
  • Reports that she occasionally misses short acting doses with meals several times a week
• Chronic Kidney Disease, Stage 3
• Hypertension
• Hyperlipidemia
• s/p 2 suspected lacunar infarcts (“mini-strokes”)
• Retinitis Pigmentosa
  • Associated cataract surgery in left eye
  • Currently in process of scheduling cataract surgery in right eye
  • Not currently treated;
• Hypothyroidism
• Sciatica
• Osteoarthritis
• Acute pancreatitis
  • o 2013
  • Reports association with unspecified hyperlipidemia drug

Trauma/Surgeries

• s/p epidural abscess drainage
  • 2010
• s/p cataract surgery left eye
  • 2008
• s/p emergent cholecystectomy
  • 1986
• s/p appendectomy (unknown year)

Obstetric Hx

• Vaginal delivery
  • 1984
  • “high risk pregnancy”
  • Gestational diabetes

Medications:

Hospital medications:

1. Furosemide: unknown dosage IV
2. Lisinopril: unknown dosage po
3. Prednisone: IV originally, now po; will be tapered after d/c
4. Enoxaparin: unknown dose bid subcutaneous injection,
5. Insulin glargine: injection, unknown dose
6. Insulin aspart: injection, sliding scale based on blood sugar

Current medications (prior to hospitalization):

1. Insulin glargine injection: 100 units at night
2. Insulin aspart injections: sliding scale per meal
3. Lisinopril: unspecified dose po qday
4. Gemfibrozil: unspecified dose
5. Levothyroxine: 88 mcg po qday
6. Tiotropium inhaler: 2 inhalations daily
7. Albuterol inhaler: 2 inhalations as needed

Allergies

NKDA

Habits and Risk Factors:

• 42 pack year smoking history
• Marijuana vaporizer use for sciatic and osteoarthritic pain
• No alcohol use
• No other recreational drug use

Family Medical History:

• Mother: died of breast cancer at 68 yo; had ‘heart problems’ with her R tricuspid valve; had diabetes
• Father: died of prostate cancer at 72; had a ‘heart attack’ prior to that
• Several other extended relatives have had cancers

Social History:

Ms. H was born in Taiwan in 1959 and spent most of her childhood there until she moved to New York to finish high school and complete college. She moved to Los Angeles after this, where she had her son. She has lived in Renton, WA for the past 4 years. Ms. H lives with her 3 dogs and her son. She reports that she retired from her work as a librarian a few years ago and is planning a trip to Taiwan in the coming months to see her 90 yo aunt.

ROS:

General: See HPI

Skin: Negative for itching, or rashes; no nail changes

Breast: Not assessed

Head: Negative for trauma

Eyes: Negative for diplopia; denies pain or discharge, positive for blurry vision; reports that vision gets worse with high blood sugars

Ears: Negative for pain or discharge

Nose: See HPI

Throat: See HPI

Pulmonary: See HPI

Cardiovascular: See HPI; Denies palpitations, claudication, or cyanosis.

Gastrointestinal/Abdomen: See HPI; denies blood in stool or change in BM quality; reports RUQ hernia

Musculoskeletal: Denies muscle or joint pain

Blood-lymphatic: See HPI; Positive for swelling in legs and abdomen;

Neurologic: See PMH; positive for left sided weakness in upper extremity and face

Psychologic: Negative for mood changes; attributed sleep changes to cough

Physical Exam:

General: Ms. H is a pleasant and alert patient who appears comfortable while lying slightly upright in her bed

Vital Signs: BP 145/85, HR 60, RR 14

Skin: warm, dry

HEENT

Head: Normocephalic; atraumatic, without scalp lesions; slight left-sided facial droop

Eyes: Visual acuity not assessed; visual fields decreased peripherally in all quadrants; funduscopic exam not assessed; conjunctivae non-injected; sclerae non-icteric; pupils 2 mm and non-reactive to light bilaterally; anterior chamber clear with no visible scarring; red reflex not assessed; no strabismus; EOMI, no nystagmus

Ears: No pain on manipulation of helix, tragus, or mastoid bilaterally; hearing intact to finger rub bilaterally; external canals clear, non-erythematous, and non-bulging; cone of light visualized;

Nose: External nose without lesions or asymmetry; internal nose dry with no discoloration; no discharge; septum midline

Mouth/Throat: Good dentition; tongue dry; uvula midline; no pharyngeal erythema or exudate; symmetrical palatal rise to phonation

TMJ: Not assessed

Neck/Thyroid: No palpable cervical, submandibular, or supraclavicular lymphadenopathy; unable to palpate thyroid

Chest: Clear lung fields; bilaterally resonant? to percussion; no respiratory distress

CV: Distant heart sounds; JVP 6 cm; unable to feel PMI; regular rate and rhythm; no heaves or thrills; no bruits in carotid; trace LE edema

Pulses: Radial pulses 2+ bilaterally symmetrical; Dorsalis and Tibialis pulses 2+

Abdomen: Appears rotund and soft; midline scar approximately 10 cm in length that was flat and non- erythematous; RLQ scar approximately 7 cm in length that was flat and non-erythematous; normal bowel sounds; Tenderness to palpation in Right upper quadrant without guarding in this region; No rebound tenderness; Unable to palpate liver; Spleen not assessed; negative fluid wave and equivocal shifting dullness exam

Genital: Not performed

Rectal: Not performed

MS: Symmetric bulk and tone

Neurologic:

Mental status: alert; cooperative; appropriate; oriented to person, time, and place; short term memory intact

Cranial Nerves:

II: Vision intact (tested with extraocular movements); decreased peripheral vision in all fields III,IV,VI: Full extraocular movements

V: Masseter strength normal; increased sensation on L side of face in V1, V2, and V3

VII: slight lower facial droop, decreased strength in L buccinators muscle; bilaterally symmetric in other muscles of facial expression

VIII: Hearing intact to finger rub bilaterally

IX,X: Normal palatal rise to phonation with no uvular deviations XI: Symmetric bulk and tone; 4+ strength on left, 5 on right

XII: Tongue deviates towards the right

Motor strength: 5/5 upper and lower extremities on the right; 4/5 on L biceps flexion, wrist flexion, finger abduction, and finger squeeze; all others, 5/5

Deep Tendon Reflexes: Symmetrical bilaterally; Biceps and triceps tendons: 1/4, brachialis tendon: 1/4, patellar tendon: 0/4, Achilles tendon: 2/4, Babinski: down-going toes

Sensation: light touch sensation intact in bilateral feet; pinprick and vibration not assessed

Coordination: Gait normal; Finger-nose test and heel-shin test not assessed; Romberg sign not assessed

Assessment and Plan:

Ms. H is a 57 yo woman with a hx of COPD, diabetes, CKD, and a 42 pack year smoking history who presented with a subacute and progressively worsening productive cough and SOB, edema, and fever.

After her course of treatment with furosemide and abx, her exam is now notable for clear lung fields, trace edema in LEs, and a JVP of 6 cm.

1. Subacute and progressively worsening productive cough and SOB

Ms. H’s chief complaint was her worsening cough over the time period of about a month and a half. Given her associated symptoms of rhinorrhea and sore throat, it is possible that her initial symptoms began as a URI. Her associated symptoms also caused Ms. H to delay seeking care because she thought that she was merely suffering from the ‘common cold’. Her continued cough, worsening PND, ascites and LE edema, and chest pain imply that she likely suffered from a COPD exacerbation and potentially left and right sided CHF. 70 % of COPD exacerbations are triggered by respiratory infections and comorbidities, such as diabetes also increase the likelihood. Other possibilities for her SOB and worsening cough include, pneumonia, heart failure, PE, and pneumothorax. Given the subacute nature of her symptoms, PE and pneumothorax are less likely, although pneumothorax should be ruled out by a CXR given in the ED when she arrived. Heart failure is still a possibility even if she had a COPD exacerbation and is suggested by her PND, ascites and LE edema, worsening SOB, and also by her chest pain and associated diaphoresis. This is likely why an echocardiogram was ordered; which Ms. H reported looked “okay” – HFpEF remains a diagnostic consideration. Pneumonia is also a possibility given Ms. H’s associated fever, productive cough, and nausea. A CXR would help determine if pneumonia was present as well.

Plan:

Many COPD exacerbations can be managed in the outpatient setting unless the patient has a serious comorbidity, such as pneumonia, heart failure, diabetes, or renal failure (among others). Given Ms. H’s comorbidities and severity of symptoms, hospitalization was required.

While in the hospital, Ms. H should receive the following:

1. systemic glucocorticoids, in the form of prednisone, 40 mg po qday, for 5-14 days depending on how she responds.
2. antibiotics (required for moderate to severe COPD exacerbations that require hospitalization) -> if risk factors are present for pseudomonas (multiple rounds of abx (>4) in last year, or multiple hospitalizations), give a fluoroquinolone; if rfs not present, give ceftriaxone. Continue abx for 3-7 days (3 days if azithromycin). Ms. H was started on ceftriaxone and azithromycin and I would suggest stopping the regimen at d/c.-If symptoms support a viral cause, such as influenza, antivirals may be indicated
3. supportive measures: cigarette smoking cessation/counseling, thromboprophylaxis such as enoxaparin, nutritional support
4. consider greater counseling on prognosis and importance of medication adherence

2. Diabetes

Ms. H currently controls her diabetes with long acting and short acting insulin outside of the hospital. Given her long history of diabetes and her high dose of lantus, continuing her insulin therapy in the hospital during her treatment is appropriate. Diabetes can make the likelihood of respiratory infections as well as COPD exacerbations greater, so counseling her on the way the two diseases affect one another is vital. It has been found that patients with higher A1C levels have lengthier and more stays in the hospital than those with nl-slightly raised levels. Generally while in the hospital, it is important to avoid hypoglycemia as well as major hyperglycemic events. Additionally, it is important to counsel Ms. H on the effect that diabetes and high blood sugar levels may be worsening her CKD and RP.

Plan:

1. check blood sugar levels before each meal and after insulin correction is given-start low correction insulin
2. give home dose insulin glargine each night
3. counsel on importance of blood sugar control for course of her comorbidities

3. Chronic Kidney Disease, Stage 3

Plan:

Inpatient: monitor kidney function with BMP every morning

Outpatient: continue Lisinopril therapy and monitoring Cr/BUN per PCP; also focus on decreasing BP to below 130/80 with presence of proteinuria

4. Hypothyroidism

Plan: Inpatient: continue levothyroxine at home dose qday Outpatient: continue therapy per PCP

5. Hypertension

Plan:

Inpatient: furosemide at start of hospital stay; continue home dosage of Lisinopril qday Outpatient: consider adding a diuretic to her Lisinopril to reach goal BP of under 130/80

Hyperlipidemia Plan:

Inpatient: continue gemfibrozil at home dosage qday; discuss possible statin tx Outpatient: continue therapy per PCP

7. Disposition/Discharge criteria:

-no signs of infection such as fever or chills

-wean O2 as tolerated; may need need home O2 short-term if unable to wean

-optimization of volume status