I was placed in New York-Presbyterian Queens for Long Term Care for 5 weeks. There I saw a wide range of acute and chronic illnesses. I saw many cancer, COPD, and CHF patients. My physical exam skills and treatment plans improved. Here are some artifacts from my rotation.

H&P 1 

Taiba Shah

LTC History and Physical 1

 

Identifying Data:

Name: J.S.

Age: 83 years old

Sex: Female

Race: Caucasian

Date & Time: 10/31/2020, 10:25 AM

Date Admitted: 10/31/2020

Location: New York Presbyterian Queens

Source of Referral: None

Source of Information: Self and daughter

Mode of Transport: driven son in law

 

 

CC: slurred speech and unwitnessed fall x 1 day

 

HPI: 83-year-old Caucasian female with PMHx of HTN controlled, HLD, CAD, MI stent x1 placed in 1980, hypothyroidism, and unspecified arrhythmia with no pacemaker presented with son-in-law to the ED on the evening of 10/30/2020 with complaints of slurred speech, syncopal episode and unwitnessed fall. Pt is a poor historian, however at baseline pt is A&O x 3 currently she is A&O x3 with periods of confusion, therefore history was obtained from patient and daughter. On the afternoon of 10/30/2020, the patient was sitting at home and talking on the phone with her friend around 15:00hrs and noticed her own speech was slurred. She spoke to the husband after, who also noted her slurred speech which lasted about 30 minutes. Around 16:00hrs she was washing dishes when she suddenly fell and hit her head. She states she fainted and did not trip on anything. The fall was unwitnessed and when she woke up she sat on a chair. Pt noted tingling sensation on bilateral fingers which lasted about 10 minutes after the fall and adds she did not fall on her hands. At baseline J.S. is able to ambulate freely without any assistance. The patient also complained of mild, dull, non-radiating, substernal chest pain and nausea at the time of the fall that lasted about 5 minutes. She states the pain was less severe than when she had an MI. She called her cardiologist Dr. Alexander Morton who told her to come in. The pt went alone to his office across the street, and the doctor attributed her symptoms to arrhythmia and gave her a holter monitor. When she arrived home she called her son-in-law and explained to him the events and he picked her up and brought her to the ED.

 

Upon arrival to the ED the patient was noted to be alert and slightly confused. She denied chest pain in the ED. Pt complained of mild headache around the area of a right posterolateral hematoma. Her speech was no longer slurred and after history was obtained, a stroke code was called. After assessment she had a NIHSS of 0. A stat CT scan was positive for acute infarct at posterior superior left temporal lobe. EKG was obtained which showed sinus rhythm, heart rate of 82, 2 sets of troponins were negative <0.010. Pt was out of the TPa window and she was not a candidate for thrombectomy. Pt received aspirin, acetaminophen for the pain, Zofran for the nausea and allowed permissive hypertension.

 

Currently J.S. has no complaints of slurred speech, chest pain, nausea or headache. Pt was stable and required admission to the medicine floor for further work up and MRI. Daughter at bedside states that pt is more confused now which is different from her baseline. J.S. continues to deny fever, chills, body aches, SOB, vomiting, dizziness, headache, visual disturbances, chest pain, diaphoresis or jaw pain during the chest pain, and focal weakness. She passed speech and swallow and is able to tolerate a full diet. J.S. is able to ambulate without assistance. She is full code.

 

 

Present illnesses:

Hypertension x 30 years

1. Well controlled, pt is compliant with medications

Hyperlipidemia x 30 years

1. Pt states she has been managing it with diet changes

CAD x 30 years

1. On maintenance medication

Hypothyroidism x 30 years

1. On maintenance medications

Unspecified arrhythmia  x 1 year

1. Recently diagnosed pt states she is following up with outpatient cardiologist
2. On maintenance medications

 

Past Illnesses:

Myocardial infarction- year- 1980

 

PSH:

Cardiac catheterization-stent placed x 1- 1980

 

Hospitalizations:

Hospitalized for MI on 1980 no complications, denies other hospitalizations

 

Family History: Unable to obtain family history because the patient was adopted.

 

Immunizations: Childhood and adult immunizations are up to date. Receives annual influenza vaccinations

 

Screening: Colonoscopy done in 2013- unremarkable as per patient

mammogram – 2010 years ago- unremarkable as per patient

Vision screen- 2019- no need for vision correction

 

 

Allergies: Denies any known allergies to medications, foods or environmental factors.

 

Medications:

Aspirin 81 oral delayed release tablet: Hx, 1 tab(s) orally once a day  -Indication: CAD

• Last dose yesterday morning

Lisinopril 20 mg oral tablet: Hx, 1 tab(s) orally once a day  -Indication: HTN

• Last dose yesterday morning

Sotalol 80 mg oral tablet: 0.5 tab(s) orally 2 times a day  -Indication: arrhythmia

• Last dose yesterday morning

Metroprolol 25 mg oral tablet: orally 2 times a day- indication: HTN

• Last dose yesterday morning

Levothyroxine 50 mcg oral tablet once a day-indication: Hypothyroidism

• Last dose yesterday morning

 

Social History:

 

J.S. is a 83 year-old-female who lives with her husband in a house in Flushing. She is a retired secretary from a law firm. She provided her daughter’s contact information as an emergency contact. J.S. denies ETOH use, tobacco use and illicit drug use. At baseline the patient walks without any assistance. She states there are 4 steps in front of her house, which she has no trouble going up. She has no home health aide. Pt denies use of a walker, cane, and sock aids. J.S stays active by going out for walks with her dog. She eats 3 meals a day and tries to keep a low salt diet. J.S. reports she sleeps 6-7 hours per night. She is currently sexually active with one partner and does not use condoms. J.S. denies recent travel and utilizes appropriate safety measures.

 

 

Review of Systems:

General – Denies recent weight loss or gain, loss of appetite, generalized weakness/fatigue, fever or chills, or night sweats.

 

Skin, hair, nails – Denies changes in texture, color, excessive dryness or sweating, moles/rashes, pruritus or changes in hair distribution.

 

Head – Admits to loss of consciousness and head trauma. Currently denies headaches. Denies vertigo, coma, fracture

 

Eyes – Denies other visual disturbances, photophobia, use of contact lenses or glasses, fatigue, lacrimation, and pruritis. Last eye exam 2019 visual acuity corrected 20/20 OU.

 

Ears –Denies deafness, ear pain, discharge, tinnitus or use of hearing aids.

 

Nose/sinuses –Denies discharge, obstruction or epistaxis.

 

Mouth/throat – Admits to permanent dentures. Denies bleeding gums, sore tongue, sore throat, mouth ulcers, voice changes. Last dental exam 2018, normal.

 

Neck – Denies localized swelling/lumps or stiffness/decreased range of motion

 

Pulmonary system – Denies dyspnea, dyspnea on exertion, cough, wheezing, hemoptysis, cyanosis, orthopnea, or paroxysmal nocturnal dyspnea.

 

Cardiovascular system – Admits to arrhythmia, syncope Denies current chest pain. Denies edema, or known heart murmur

 

Gastrointestinal system – Denies change in appetite, nausea, vomiting, abdominal pain, dysphagia, pyrosis, unusual flatulence or eructation, constipation, diarrhea, jaundice, hemorrhoids, rectal bleeding, or blood in stool.

 

Genitourinary system – Denies urinary frequency or urgency, nocturia, oliguria, polyuria, dysuria, incontinence, awakening at night to urinate or flank pain.

 

Nervous – Pt admitted to tingling sensation on b/l fingers after she fell. She denies having the sensation currently.  Admits to loss of consciousness. Denies, ataxia, loss of strength, change in cognition / mental status / memory, or weakness.

 

Musculoskeletal system – Denies joint pain, deformity or swelling,

 

Peripheral vascular system – Denies intermittent claudication, varicose veins, edema, coldness or trophic changes.

 

Hematological system – Denies anemia, easy bruising or bleeding, lymph node enlargement, blood transfusions, or history of DVT/PE.

 

Endocrine system – Denies polyuria, polydipsia, polyphagia, heat or cold intolerance, excessive sweating, hirsutism, or goiter

 

Psychiatric – Denies depression/sadness, anxiety, OCD, visual/ auditory hallucinations and seeing a mental health professional.

 

 

Physical Exam:

 

VITALS

Tc: 36.6 oral Tmax: 37.2

HR: 57 (57 – 74) regular

BP: 136/76 (126/66 – 175/123) left arm sitting

SpO2: 93% (92 – 97), Room Air,

RR: 17 unlabored (14 – 20)

Height: 64inches

Weight: 156 lbs

BMI: 27.63

 

 

 

General: J.S. appears stated age, well groomed, good hygiene, NAD, AAOx3 with periods of confusion, often requiring redirection, lying comfortably in a stretcher. She is calm and cooperative.

 

Skin: Skin is warm, moist. Multiple 1cm-2cm brown/back raised nevi on the entirety of back. Nail beds pink with no cyanosis or clubbing. Capillary refill 2 seconds throughout

 

 

Head: 3cmx 2cmx 2cm right posterolateral scalp hematoma with erythema, no bleeding. Mildly tender to palpation, No depressions, or scarring. Hair is fine, and evenly distributed.

 

Eyes: Symmetrical OU, no evidence of strabismus, exophthalmos or ptosis; sclera white non-icteric, conjunctiva and cornea clear, visual acuity corrected 20/20 OU, 20/20 OS, 20/20 OD. Visual fields full OU PERRL with slurred accommodation. EOMs full, with no nystagmus. Fundoscopy; not assessed

 

Ears: Symmetrical, normal size. No evidence of lesions/masses trauma on the external ear. No mastoid tenderness. External ear canal is non-tender without swelling or erythema and without discharge or FB AU. Tympanic membrane is pearly grey and intact with cone of light in normal position AU. Good acuity to whispered voice AU.

 

Nose/Sinuses: Nasal mucosa is pink and moist, clear discharge. The nasal septum is midline. Nares are patent bilaterally, no FB.  No pain on palpation and percussion over b/l frontal, ethmoid, and maxillary sinuses.

 

Mouth and pharynx: Lips: pink moist, no evidence of cyanosis or lesions, non-tender to palpation. Oral mucosa is pink and moist. Permanent dentures seen. Tongue pink and well papillated, no masses, lesions, or deviation noted.

 

Palate: pink, well hydrated, intact, no lesions. Tongue pink well papillated, with good symmetrical movement. No buccal nodules or lesions are noted. The pharynx is mildly dry, no evidence of injection, exudate masses, lesions or foreign bodies. Tonsils presents with no evidence of injection or exudate.

 

Neck:  Trachea is midline. The neck is supple without adenopathy. No masses, lesions, scars Thyroid gland is nontender without masses, no thyromegaly or bruits. Carotid pulse 2+ bilaterally without bruit. FROM. No JVD.

 

CV/chest: The external chest is symmetrical, no deformities, signs of trauma, lifts, heaves, or thrills. Chest wall is non-tender. PMI is not visible and is palpated in the 5th intercostal space at the midclavicular line. Heart rate is bradycardic 55 bpm and rhythm is normal, S1 and S2 are normal. Carotid pulses are 2 +. No murmurs, S3 and S4, gallops, or rubs are auscultated.

 

Lungs: The chest wall is symmetric and without deformity. Respirations are unlabored. No signs of trauma. No signs of respiratory distress, chest expansion is symmetrical. Lung sounds are clear to auscultation in all lobes bilaterally without rales, ronchi, or wheezes. Resonance is l upon percussion of all lung fields. Tactile fremitus intact throughout

 

Abdominal: Abdomen is soft, symmetrical, without scarring. No caput medusae. Active bowel sounds are present in all 4 quadrants. Aorta is midline without bruit or visible pulsation. Tympany to percussion throughout. Non-tender to percussion and light palpation. Umbilicus is midline without herniation. No masses, hepatomegaly, or splenomegaly are noted. No guarding or rebound, CVA tenderness noted b/l. Non tender on McBurney’s point. Negative Murphy’s sign, negative poas, negative obturator, negative rovsing.

 

Genitourinary: not assessed

 

Rectal: not assessed

 

Extremities: No ecchymosis / atrophy / edema or deformities in bilateral upper and lower extremities. Non-tender to palpation / no crepitus noted throughout. FROM of all upper and lower extremities bilaterally.  No evidence of spinal deformities.

 

Peripheral vascular: Extremities are normal in color, size and temperature. Pulses are 2+ bilaterally in upper and lower extremities. No bruits noted. No clubbing, cyanosis or edema noted bilaterally. No stasis changes or ulcerations noted.

 

Neurological:

 

Mini Mental Status exam:

The patient is awake, alert and oriented to person, place, and time with periods of confusion, she often needs redirection. She nods to open ended questions. She is able to follow commands, able to name and repeat. No dysarthria noted.  3/3 recall after 3 minutes. Motor function is intact with muscle strength 5/5 bilaterally to upper and lower extremities. Sensation is intact bilaterally. Reflexes not assessed.

 

Cranial Nerve Exam

I – not assessed

II- Visual acuity corrected 20/20 OU, 20/20 OS, 20/20 . Visual fields by confrontation full. Fundoscopy not assessed.

III-IV-VI- PERRL with slurred accommodation accommodation is , EOM intact without nystagmus.

V- Facial sensation intact, strength good.

VII- Facial movements are symmetrical and without weakness.

VIII- Hearing grossly intact whispered voice bilaterally.

IX-X-XII- Swallowing intact. Uvula elevates midline. Tongue is midline

XI- Shoulder shrug intact. Sternocleidomastoid and trapezius muscles strong.

 

– Motor: Normal bulk / tone / strength throughout.  Fine finger movements equal bilaterally. No tremors.

– Sensory: intact/symmetrical to light touch throughout. No right to left confusion. Possible RIGHT neglect.

– Gait: Steady Gait Romberg negative

Cerebellar function is intact. Pt was able to ambulate to the bathroom with no assistance. Full active and passive ROM of all extremities without rigidity or spasticity. No atrophy, tics or fasciculations. Strength was equal and appropriate for age bilaterally. No gait abnormalities are appreciated.

 

 

Lab Results:

1st set: Troponin: <0.010

 

2nd set: Troponin: <0.010

 

140 | 101 | 11.3

——————–< 116   Ca: 9.8   Anion Gap: 14

3.6 |  25 | 0.65

 

WBC: 12.77 / Hb: 13.8 (MCV: 87.7) / Hct: 41.2 / Plt: 312

—  Diff: N:81.4%  L:11.70%  Mo:5.7%

 

PT: 11.6 / PTT: 44.4 / INR: 1.02

 

Prot: 7.1 / Alb: 4.5 / Bili: 1.1 / AST: 24 / AlkPhos: 87

 

Radiology/Other Results:

CT Head Impression:

1. Findings most likely representing infarct, centered at the

posterior superior left temporal lobe.

2. Findings of atherosclerosis, atrophy, and chronic small vessels

ischemic disease.

3. Scalp hematoma posterolaterally on the right.
4. No intracranial hemorrhage seen.

 

CT C Spine Impression:

1. Degenerative disc and joint disease.
2. Mild multilevel spondylolisthesis, most likely

chronic/degenerative.

3. Associated narrowing of foramina (left more than right), and to

lesser degree spinal canal, as above.

4. Thyroid right atrophic.

-Correlation with thyroid function tests recommended.

5. No cervical spine fracture seen.

 

CXR Impression:

 

1. No acute cardiopulmonary abnormality seen.
2. Findings suggesting COPD/emphysema, and mild pulmonary scar.
3. Skeletal findings as above.

 

Other Data:

-ECG showed sinus rhythm, HR 82

 

 

Assessment:

83 y.o. female with pmhx of HTN, HLD, MI stent placed in 1980, hypothyroidism, and unspecified arrhythmia was BIB by son in law to the ED for slurred speech and syncopal episode/unwitnessed fall. In the ED she had a NIHSS of 0 and CT showed posterior superior left temporal lobe. Pt will be admitted for further work-up to rule out atrial fibrillation, uncontrolled hyperlipidemia, delirium, and assess for any further cerebral ischemia.

 

 

Plan:

1. Stroke, posterior superior left temporal lobe infract.
   1. NIHSS =0 in the ED
   2. Will allow for permissive HTN for cerebral perfusion
   3. Not a candidate for tPA since patient outside treatment window
   4. continue home med Aspirin 81mg and start Clopidogrel 75 mg 1 tab PO daily for 3 weeks then monotherapy with Clopridorgrel 75 mg.
   5. Pt will be placed on Telemetry while inpatient
      1. troponin negative x2, will continue to trend one more set
      2. follow up ECG in the AM
   6. Continue Acetaminophen 325 mg 1 tab PO PRN if pt has headache
   7. Continue Zofran 8 mg 1 tab PO PRN if patient has nausea
   8. Follow up CTA head/neck to evaluate for vascular patency
   9. MRI brain non-cont ordered, follow up on results
   10. Follow up HbA1c, TSH and lipid panel, folate, vitamin B12, homocysteine
   11. TTE ordered, follow up on results
   12. PT/OT consulted
   13. Neuro evaluation and recommendation in the AM
   14. Neuro checks every 4 hrs, fall precautions, monitor vitals daily

 

2. Hyperlipidemia
3. Start Lipitor 40 mg 1tab PO once daily

 

3. Hypertension
4. Hold home meds Lisinopril 20 mg due to permissive hypertension will monitor BP and if increased will add back on.

 

4. hypothyroidism
5. Check TSH in the AM, if hypothyroid continue home med Levothyroxine 50 mcg oral tablet once a day

 

5.Unspecified Arrhythmia

1. Follow up on holter monitor placed by outpt cardiologist. Pt is on telemetry
2. Contact pt’s outpt cardiologist on Monday
3. In setting of bradycardia will hold home sotalol and will continue to monitor for arrythmias
4. Will hold home Metroprolol 25 mg to allow for permissive hypertension
5. Pt will be assessed for A fib possible consult with EP

 

6. Passed bedside speech and swallow eval, pt may eat
   1. Low salt diet
   2. R/o delirium
   3. Follow up on UA results
   4. Preform Mini-mental status exam

 

8. Full code.

 

9. GI/DVT prophylaxis

1. Pantoprazole Inj 40 mg IV push daily
2. Enoxaparin inj 40 mg subcutaneous daily

 

10.COVID Risk

1. Low suspicion of COVID 19 infection based on clinical judgement of patient being afebrile, inflammatory markers negative, CXR negative for bilateral focal consolidations/ infiltrates. Transfer patient to COVID negative unit.

 

Typhon totals

Journal Article

I presented a Cochrane systematic review which included 32 trials with 28,672 participants. This study examined whether healthcare providers have taken enough initiative to counteract the negative consequences of polypharmacy. These actions include providing a service known as pharmaceutical care (promotes correct use of medications) in addition to using computerized decision support (program on computer aiding in selection of appropriate treatment) and pharmacy led interventions. The first primary outcomes of interest in this review were medication appropriateness (as measured by an implicit tool), potentially inappropriate medications (PIMs) and potential prescribing omissions (PPOs). The main results compared interventions, however, there was no definitive conclusion as to just how effective said interventions were. The results were interesting because I expected there to be a stronger positive effect of these interventions mitigating polypharmacy.

Rankin_et_al-2018-Cochrane_Database_of_Systematic_Reviews

 

Site Evaluation

The frist site evaluation  presented 1 H&P, and 5 pharm cards. I choose a patient who had a stroke. Durring my time in the rotation I saw many stroke patients. I think I did an overall good job. The feedback I received was to detail my neuro exam better. I took this feedback and took a more thorough neuro exam through the rest of my rotation. I added more details in my last two H&Ps. I also presented my article and my 5 pharm cards in my last evaluation.

 

 

Self Reflection

How could the knowledge I’ve gained here be applicable in other rotations/disciplines?

Geriatric patients are very complex. They have multiple comorbidities and they present differently than other types of patients. Usually they have really extensive surgical and past medical history. I will take the history taking skills I have gained from this rotation to my future practice. Further more my H&Ps were very detailed for LTC. I hope to keep them detailed. I would include an overview of what happened, what was done in the ED and my history in the HPI.

What was a memorable patient or experience that I’ll carry with me?

A memorable patient that I had was an 87 y.o. Mandarin speaking male who was admitted for sepsis workup. He was so frail and malnourished. When I met him, he had an injury on his arm. The night before he was about to fall out of bed when a nurse heard the alarm she went to his room and grabbed his arm to prevent the fall. This caused an injury to his arm where his skin ripped off his arm. This incident show the level of frailty this patient was in. I saw him in the morning and he was aggravated, I helped move him and he was attempting to punch each person helping. He was deliours. I checked his labs right after and noted to the PA his glucose was 28. That could have been the reason for his aggrevation. I went to his room and helped him drink ensure while we waited for the nurse to give D5W. I spent a lot of time with this patient. He told me about his wife and he tried messaging her what food he wanted her to bring. I was sad to find out the next day he passed away. This was the first passing of a patient I had a rapport with.

What one thing would you want the preceptor or other colleagues to notice about your work in this rotation?

I would want my preceptor to notice how proactive I was. Usually the PAs were very busy during their shifts. I would read up on all the patients on their lists and I would pick a few to follow that week. I would ask the PA I was with if I can do histories and physicals. I came during weekends because there weren’t any students and therefore more opportunities to learn. I requested to come in on an extra weekend to work in the ICU and learn how to manage ICU patients. I followed phlebotomists and did blood work, and the mid line team, I also went to rapid response calls. I would like my colleagues to know how I tried to look for opportunities to learn.

What do you want to improve on for the following rotations? What is your action plan to accomplish that?

I would like to improve my IV skills. I didn’t have many opportunities to place IVs. The ones I did do were successful. However, I would like to practice more to have a routine and ease with placing an IV. I believe in ER rotation I will be able to have more opportunities to place IVs.