BAYPATH SOAP NOTE Chronic Disease (1)

SOAP NOTE# 2

Subjective

CC: Chronic Disease Management 

 HPI:

E.I. is a 90-year-old male referred from Spaulding Rehab Hospital after a stay at Mass General, where he presented after a fall from his assisted living facility. He was found to have severely comminuted left acetabular fracture, minimally displaced left inferior pubic ramus fracture, and right subdural hematoma. He was treated conservatively, touched down weight bearing, and was started on Lovenox for prophylaxis. He is referred to us for further rehab and continues with touchdown weight bear status. He is not continued with Lovenox, and this was clarified with ortho. He is on scheduled Tylenol and tramadol for pain control. He has a background of diabetes and is referred on Lantus and scheduled lispro with meals which MD has authorized himself to self-administer. He was referred on Lasix 20 mg daily for CHF, which we have increased to 40 mg daily with good effect. He complains of some bowel issues expressing urgency and diarrhea at times. He had a neurosurgery follow-up earlier in the month, is now on aspirin and will have a repeat head CT in 8 weeks. He had normal BMP and iron levels in April. We continue to discuss his loneliness, and he continues to struggle with the loss of independence and adjusting to LTC.

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ALSO READ: EVIDENCE BASED PRACTICE

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Past Medical Hx

Aortic stenosis

Prostate cancer

Cholecystitis

CHF

Type 2 diabetes

GERD

Hyperlipidemia

Hypertension

Surgical History

Toe amputations

Cholecystectomy

Bilateral cataract extraction

Cardiac stent

Family Hx

The patient is a widower who lost his wife 20 years ago. He has no living family

Social Hx

He is a non-smoker and lives in an assisted facility.

Allergies

No known food, environmental or medication allergy.

Current Medications

Insulin Lispro (1 Unit Dial) 100 UNIT/ML Solution pen-injector as directed subcutaneous 

Lantus Solostar 100 UNIT/ML solution Pen-injector as directed subcutaneous

Atorvastatin calcium 40 mg Tablets, 1 tablet Orally once a day

Tamsulosin HCI 0.4 mg Capsule; 1 Capsule orally once a day

Lidocaine 4% Patch as directed internally

Calcium Carb-Cholecalciferol 600-400 MG-UNIT Tablet with meal orally Twice a day

Cholecalciferol 25MCG (1000UT) Tablets, 1 tablet orally once a day

Primidone 50 mg Tablets 0.5 Tab orally once a day

Aspirin 81 mg Tablet Delayed-Release, 1 tablet Orally Once a day

Furosemide 40MG tablet Orally once a day

Acetaminophen 325 MG Tablet 2 tab Orally twice a day

Tramadol HCI 5OMG Tablet 2 tab orally twice a day

Lyrica 25MG Capsule 1 Orally once a day

Objective (PE)

VS: T- 97.6° F, BP- 106/ 68 mmHg, RR- 18 bpm, HR- 66 bpm, SPO2- 97% WT. – 171 lbs FS’s 126-272

Constitutional: General Appearance: appropriate. Level of Distress: NAD. Ambulation: ambulating normally.

Psychiatric: Mental Status: normal mood and affect and active and alert, calm and cooperative. Orientation: to time, place, and person.

Head: Head: normocephalic and atraumatic.

Eyes: Lids and Conjunctivae: no discharge or pallor and non-injected. Pupils: PERRLA. Corneas: grossly intact. Sclerae: non-icteric. Vision: peripheral vision grossly intact and acuity grossly intact.

ENMT: Ears: no lesions on the external ear, EACs clear, TMs clear, and TM mobility normal. Hearing: no hearing loss. Nose: no lesions on external nose, septal deviation, sinus tenderness, ongoing runny nose and postnatal drip. Oropharynx: no erythema or exudates and moist mucous membranes and tonsils not enlarged.

Neck: Neck: supple, FROM, trachea midline, and no masses. Thyroid: no enlargement or nodules and non-tender.

Lungs: Respiratory effort: no dyspnea. Percussion: no dullness, flatness, or hyper resonance. Auscultation: no wheezing, rales/crackles, or rhonchi, and breath sounds normal, reduced aeration left base noted.

Cardiovascular: Apical Impulse: not displaced. Heart Auscultation: regular S1 and S2 with 2/6 SEM; no murmurs, rubs, or gallops; and RRR. Neck vessels: no carotid bruits. Pulses including femoral / pedal: normal throughout.

Abdomen: Normoactive Bowel Sounds. Inspection and Palpation: no tenderness, guarding, masses, rebound tenderness, or CVA tenderness and soft and non-distended. Liver: non-tender and no hepatomegaly. Spleen: non-tender and no splenomegaly. The patient reports diarrhea at times and bowel issues with expressing urgency

BLE: with trace oedema, venous discoloration and some excoriated areas.

Musculoskeletal: Motor Strength and Tone: normal tone and motor strength. Joints, Bones, and Muscles: no contractures, malalignment, tenderness, or bony abnormalities and normal movement of all extremities. Extremities: no cyanosis, oedema, varicosities, or palpable cord.

Neurologic: Non-focal Cranial Nerves: grossly intact. Some short-term memory loss

Skin: Inspection and Palpation: no rash, ulcer, induration, lesion, nodules, jaundice, or abnormal nevi and good turgor. Nails: normal.

Back: Thoracolumbar Appearance: normal curvature. Lumbar / Lumbosacral Spine normal extension and flexion and Motion Quality WNL, no spasms, and Palpation tenderness none.

Labs: Transthoracic echocardiogram, ECG, CT scan, Fasting blood sugar tests

Assessment 

Diagnosis: 

1. Chronic diastolic (Congestive) Heart failure- I50.32 (Primary)- The patient has a history of Chronic diastolic (Congestive) Heart failure, has edema and venous discoloration.
2. SDH (Subdural hematoma)- S06.5X9A- Patient had a fall, short term mild memory loss
3. Type 2 Diabetes Mellitus with other circulatory complications- e11.59 – Patient had a history of Type 2 Diabetes Mellitus; patient has venous discoloration and some excoriated areas.
4. GERD without esophagitis- K21.9 – The patient had a history of GERD
5. Postnasal drip- R09- 82- The patient has an ongoing runny nose and postnatal drip.
6. Loneliness- Z65.8 – The patient has no living family, he is losing his self-independence and living in an assisted care facility that he is having trouble adjusting to.

Differentials: 

1. Chronic obstructive pulmonary disease (COPD) J44.1 - The patient has oedema but denies difficulty breathing and shortness of breath.
2. Subdural hematoma S06.5 – The patient had a fall at his assisted living and has some mild short-term memory loss. However, he denies any nausea, vomiting or dizziness.
3. Metabolic syndrome E00-E89- It is common for people over 60 years and low physical activity. However, his BP and BMP are normal, and he is a non-smoker.
4. Gastritis K 29.0 – The patient reports bowel issues with expressing urgency. However, his iron levels are normal, indicating no anaemia caused by gastritis.
5. Allergic Rhinitis J30.9 – The patient has an ongoing runny nose and postnatal drip. However, he denies fever and cough
6. Depression F32. 1 – The patient is lonely and struggling with loss of independence and living in an assisted facility. The patient denies sleep changes and irritability.

Plan 

• The patient was advised to continue with the current medications.
• The patient was started on aspirin and had a repeat imaging in July.
• The patient had his sugars reviewed and appear stable on the insulin regimen.
• Due to diarrhea, at times the patient needs to discontinue omeprazole and start famotidine 20 mg orally 2 times a day.
• Patient to start on cetirizine for postnasal drip, 5 mg orally once a day
• Counselling therapy.

Patient Education 

-Educated the patient on the importance of taking medications as directed, eating healthy diets, and regular check-ups to alleviate the chances of developing other symptoms of his conditions (Rusus et al., 2020).

-Patient was educated on side effects of diabetes medications such as nausea, gas, bloating, diarrhea, and an upset stomach. Patient was advised to take the medication with to reduce some of the side effects.

-Patient was also educated on side effects of hypertension medications, which often cause dehydration and electrolyte imbalance. The patient was advised to inform the doctor right away if he experiences any of the side effects such as muscle cramps, weakness, abnormal fatigue, confusion, severe dizziness, fainting, drowsiness, abnormal dry mouth or thirst, nausea, vomiting, and irregular heartbeat.

-Patient education was done mainly on offering support and counselling as the patient experiences loneliness and difficulties accepting his ailments and requires so much assistance.

-Follow-up appointments every two weeks was recommended for the patient to manage the progression of his ailments.

Rationale:

• The patient has type 2 diabetes, but his sugars have been reviewed and are stable; hence should maintain his insulin regimen.
• The patient reports diarrhea at times and bowel issues with expressing urgency. He has to be discontinued on omeprazole as it can cause diarrhea by itself of ​​variable intensity and prescribed famotidine for his GERD.
• The patient has difficulty accepting his ailments and is struggling with losing independence (Perissinotto et al., 2019). He needs counselling therapy to deal with the loss of independence, social isolation, living in an assisted facility and poor physical health.

References

Perissinotto, C., Holt‐Lunstad, J., Periyakoil, V. S., & Covinsky, K. (2019). A practical approach to assessing and mitigating loneliness and isolation in older adults. Journal of the American Geriatrics Society, 67(4), 657-662.

Rusu, A., Randriambelonoro, M., Perrin, C., Valk, C., Álvarez, B., & Schwarze, A. K. (2020). Aspects influencing food intake and approaches towards personalizing nutrition in the elderly. Journal of Population Ageing, 13(2), 239-256.