LTC H&P #2                                                              Julia Wadolowska

Date: 10/26/21

Patient Name: PF

HPI:

         62 y/o wheelchair-bound male living in community with assistance of home health aide, with PMH of CAD, NSTEMI s/p PCI to RCA, HF with reduced EF 25%, PAD, paraplegia with left AKA s/p train accident in 1987, neurogenic bladder, DM2, HTN, HLD, decubitus ulcers to right foot and ischium, presented to ED on 9/24/21 with complaint of decreased oral intake and vomiting for about one month. Patient stated that he normally has a good appetite, eating three meals a day, but has been experiencing about one episode a day of non-bloody, non-bilious vomiting and decreased appetite for about one month resulting in eating one to two meals a day and not finishing meals. Vomiting occurred at different times of day, sometimes before eating and other times after a meal. Patient reported feeling “not fully well” for about the same time, describing it as decreased appetite, mild weakness/feeling tired, and not his “normal self”. Patient also reported chronic pain at sites of decubitus ulcers, stating that he has had the ulcers for years and pain has been increasing as the ulcers progress. Patient has been receiving wound care for ulcers for a couple years but they are not healing. Patient unsure if he lost any weight recently but stated that his clothes fit the same as before, so he does not believe he lost weight. Patient is wheelchair bound, living alone in apartment building, with home health aide assistance in hygiene, cooking, chores, and wound care for decubitus ulcers. Patient denied chest pain, fever, night sweats, SOB, cough, dizziness, syncope, hematemesis, hemoptysis, heartburn, dysphagia, abdominal pain, dark or bloody stools, diarrhea, constipation, sick contacts, recent travel, new injuries.

On assessment in ED, patient was found to be afebrile with stable vital signs. Blood work showed a WBC of 22,000 and hemoglobin of 6.7. Blood cultures were collected, and patient was initially started on Linezolid and Cefepime. Blood cultures showed MRSA bacteremia and patient was switched to IV Vancomycin. Patient was also administered 2 units of PRBCs and IV iron sucrose, with plan to start ferrous sulfate once admitted. FOBT was negative with no signs of bleeding elsewhere, Hematology diagnosed patient with anemia due to chronic disease. Imaging done included a CT abd/pelvis which showed right hip osteomyelitis with ischial ulcer. Patient was admitted to the MICU.

In MICU, patients WBC improved after antibiotics and ID recommended discontinuing antibiotics on 10/12/21 due to ischial wound having too much exposed bone for antibiotics to have any further efficacy and osteomyelitis being too advanced. On 10/20/21 patient was found to be septic again, likely secondary to recurrent ischial ulcer infection. Patient was restarted on IV Vancomycin and Cefepime. Patient experienced AKI with vancomycin and was transitioned to IV Ceftaroline on 10/22/21. Patient presented to hospital with chronic indwelling foley for neurogenic bladder, which was replaced and maintained during admission. Vomiting ceased halfway through admission with improvement in appetite, patient eating three meals a day and denying nausea or vomiting. AKI subsequently resolved and medicine deemed GI upset as secondary to bacteremia, no abnormalities found on CT abd/pelvis or other lab work to explain vomiting.

Infectious disease and orthopedic surgery discussed further treatment with patient, stating that given the extent of exposed bone, there is no way to cure right hip osteomyelitis or heal wound without surgical hip disarticulation/debridement. Patient declined surgery at this time.

Patient was deemed stable for discharge to subacute rehab for wound care as well as IV Ceftaroline to be administered until 11/04/21 to complete 14-day course of antibiotics. Psychiatry evaluation was recommended in subacute rehab to determine patients insight and understanding of condition and prognosis for hip osteomyelitis.

 

PMH
– CAD on Metoprolol succinate XL 50 mg once daily, also has nitroglycerin SL 0.4 mg but has not used since NSTEMI. Patient denies chest pain, SOB since PCI.
– NSTEMI s/p PCI to RCA, one stent (05/2021), on aspirin 75 mg once daily and clopidogrel 75 mg once daily
– HF with reduced EF 25% (last ECHO 05/2021). Patient denies any symptoms, does not exert himself during daily activities.
– PAD on Clopidogrel 75 mg once daily. Patient wheelchair bound, paraplegic, with chronic ulcer to right malleolus receiving wound care.
– paraplegia with left AKA s/p train accident 1987
– neurogenic bladder s/p train accident 1987, with chronic indwelling foley
– DM2, patient reports checking fingerstick about twice a week, usually 100-140, on Humulin NPH U-100 16 units at bedtime, patient reports compliance. Last HgbA1C 7.6 in 05/2021.
– HTN, patient reports recording blood pressure about once a week, stating that highest systolic is usually around 130, on metoprolol succinate XL 50 mg once daily
– HLD, on atorvastatin 80 mg once daily
– decubitus ulcers to right foot on and above right malleolus (stage 3, 5.5 x 6 cm) and right ischium (stage 4, 5.9 x 4 cm), present for about 6 months at current stages, wound care done twice a week at home by visiting nurse/health aide

 

Surgeries
– left AKA 1987
– PCI to RCA s/p NSTEMI 05/2021

Allergies
– Denies, NKDA

Social History

         62 y/o male living alone in apartment building, paraplegic, wheelchair bound s/p left AKA 1987 after train accident. Patient is semi-independent, able to transfer self to toilet, perform basic hygiene, go grocery shopping, and prepare food for self but has home health aide who helps with hygiene, cooking, chores, as well as caring for foley and wound care. Patient also has visiting nurse who does more in-depth care for ischial and foot ulcers. Patient is single, never married, with one brother who visits about once a month, and no children. Patient finished high school and worked as an auto mechanic until train accident, where patient syncopized on subway platform and fell into tracks, being hit by train. Syncope was deemed vasovagal at time of evaluation. Patient sustained severe injury to left lower extremity resulting in AKA, and paraplegia. Patient has been on disability and wheelchair bound since accident. Patient reports that daily diet consists of a mix of healthy snacks such as fruit and yogurt as well as fast food multiple times a week and some home-cooked meals when his health aide helps with cooking. Patient never smoked but admits to about three alcoholic drinks a month, with no drinking since NSTEMI in May of this year. Patient states that he spends his days trying to care for himself which he states he is handling well for decades, and watches sports, listens to music, and meets up with friends in local park in free time. While he is still pursuing daily activities, recent vomiting and increasing pain from decubitus ulcers has made him less active and requiring more help from health aide.

 

Family History

Patient reports hypertension in father and brother, and diabetes type 2 in mother. Both of patients parents are deceased of natural causes.

Review of Systems

General: Admits to loss of appetite. Denies fever, chills, night sweats, fatigue, recent weight loss/gain, weakness.

Skin, hair nails: Admits to decubitus ulcers on right foot and ischium, hyperpigmentation on right lower extremity. Denies recent changes in texture, excessive dryness or sweating, moles/rashes, pruritus, changes in hair distribution.

Head: Denies headache, dizziness, head trauma, unconsciousness.

Eyes: Denies lacrimation, pruritus, visual disturbances, photophobia, decreased visual acuity, wearing glasses. Last eye exam about two years ago, unknown visual acuity.

Ears: denies deafness, pain, discharge, tinnitus, use of hearing aids.

Nose/sinuses: denies discharge, epistaxis, obstruction.

Mouth/throat: Denies bleeding gums, sore tongue, sore throat, mouth ulcers, voice changes, use of dentures. Last dental exam about 3 years ago, normal.

Neck: denies localized swelling/bumps, stiffness, decreased range of motion.

Pulmonary System: denies dyspnea, SOB, cough, wheezing, hemoptysis, cyanosis, orthopnea, PND.

Cardiovascular System: admits HTN. Denies chest pain, palpitations, irregular heartbeat, edema/swelling of ankles or feet, syncope, known heart murmur.

Gastrointestinal System: Admits to vomiting, change in appetite. Denies abdominal pain, nausea, diarrhea, constipation, intolerance to specific foods, dysphagia, pyrosis, unusual flatulence or eructation, jaundice, change in bowel habits, hemorrhoids, rectal bleeding, blood in stool, flank pain. Patient denied ever having a colonoscopy.

Genitourinary System: Admits to chronic indwelling foley. Denies urinary frequency, urgency, hesitancy, dribbling, nocturia, oliguria, polyuria, dysuria, incontinence, itching, discharge.

Sexual history: patient is not sexually active. Denies history of STD’s.

Musculoskeletal System: admits to pain at ulcer sites over bone. Denies muscle pain, deformity, swelling, redness, arthritis.

Peripheral vascular system: Admits to hyperpigmentation on right lower extremity, decubitus ulcers on right ankle, right ischium. Denies intermittent claudication, coldness or trophic changes, peripheral edema, varicose veins.

Hematologic System: denies anemia, easy bruising/bleeding, lymph node enlargement, history of DVT/PE.

Endocrine System: denies polyuria, polydipsia, polyphagia, heat or cold intolerance.

Nervous system: Denies seizures, loss of consciousness, sensory disturbances, ataxia, change in strength, change in cognition/mental status/memory.

Psychiatric System: denies depression, SI/HI, auditory or visual hallucination, anxiety, obsessive/compulsive disorder, ever seeing a mental health professional, psychiatric medications.

 

Physical Exam

VS: BP: 122/80  HR: 86  RR: 16 O2 sat: 97% Temp: 98.2 F
weight: 209 lbs.    height: 5’11     BMI: 29.6

General: A&O to person, place, time. Able to recall recent and past events. Well groomed, appropriately dressed, in no apparent distress.

Skin: stage 3 decubitus ulcer on and above right malleolus (right lower leg, 5.5 x 6 cm, no exudate), stage 4 decubitus ulcer on right ischium (5.9 x 4 cm, granulation and slough, serosanguineous exudate). Skin is warm, dry, non-icteric, no scars, tattoos, moles noted. No nail pitting, clubbing. Hair of average quantity and distribution for age.

Head: normocephalic, atraumatic, non-tender to palpation.

Eyes: symmetrical OU. No strabismus, exophthalmos, or ptosis. Sclera white, cornea clear, conjunctiva pink. Mild opacity to bilateral lenses. Visual fields full OU. PERRLA, EOM’s intact with no nystagmus. Red reflex intact OU.

Nose: symmetrical, no masses, lesions, deformities, trauma, discharge. Nares patent bilaterally. Nasal mucosa pink and well-hydrated. No discharge noted on anterior rhinoscopy. Septum midline without lesions, deformities, infection, perforation. No foreign bodies.

Ears: symmetrical and normal size. No masses, lesions, trauma on external ears. No discharge or foreign bodies in external auditory canals AU. TM’s pearly white and intact with light reflex in normal position AU.

Mouth: pink, well-hydrated, intact with no lesions, masses, ulcerations. Gingiva pink, moist, with all teeth present.

Pharynx: well-hydrated. No injection, exudates, masses, lesions, foreign bodies. Tonsils present with no injection, exudates. Uvula pink, no edema or lesions.

Neck: trachea midline. No masses, lesions, scars pulsations. Supple, non-tender to palpation. No nuchal rigidity noted.

Thyroid: non-tender, no palpable masses, no thyromegaly.

Thorax and lungs: chest symmetrical, no deformities, no evidence of trauma. Respirations unlabored, no paradoxic respirations, no use of accessory muscles. Lat to AP diameter 2:1. Non-tender to palpation. Lungs clear to auscultation and percussion bilaterally. No adventitious sounds.

Cardiovascular: Carotid pulses 2+ bilaterally without bruits. RRR. S1 and S2 distinct, no S3 or S4, no murmurs. No splitting of S2 or friction rub noted.

Abdomen: flat and symmetric with no scars, striae, pulsations noted. Bowel sounds normoactive in all quadrants, no aortic/renal/iliac/femoral bruits heard. Non-tender to palpation throughout. No guarding or rebound noted. No hepatosplenomegaly to palpation. No CVA tenderness noted.

Genitourinary: no erythema, rashes, ulcers, nodules, discharge, scrotal masses or hernias. Chronic indwelling foley present without signs of infection.

Rectal: no hemorrhoids, lesions, masses noted. Stool brown, negative FOBT.

Peripheral vascular: Right lower extremity with hyperpigmentation and decubitus ulcer. Extremities normal in size, temperature. Pulses are 1+ bilaterally in upper and lower extremities. No bruits noted. No clubbing, cyanosis, or edema noted bilaterally. Capillary refill < 2 seconds throughout.

Neurologic: CN II-XII intact. Sensation intact to light touch, sharp/dull throughout. Proprioception, point localization, extinction intact bilaterally. Reflexes: 2+ on upper extremities, absent on lower. Mild atrophy to right lower extremity. No tics, tremors or fasciculations.

Musculoskeletal: 5/5 strength with active movement and FROM with flexion, extension, rotation, abduction/adduction in upper. 0/5 strength in lower extremities. Right lower extremity and ischium tender to palpation on and near decubitus ulcers.

Mental status: normal appearance and behavior, speech and language, mood, thought process and content, understands own condition, exhibits good judgment, memory, and attention, and has good cognitive function. Patient denies feeling depressed or down, denies ever seeing a mental health professional.

 

Assessment & Plan

62 y/o wheelchair bound male with PMH of CAD, NSTEMI s/p PCI, HF with reduced EF, PAD, paraplegia with left AKA, neurogenic bladder, DM2, HTN presenting with vomiting and decreased appetite. Patient diagnosed with right hip osteomyelitis, ischial decubitus ulcer stage 4, right malleolar ulcer stage 3, and anemia of chronic disease. Patient treated with antibiotics for MRSA bacteremia and 2 units PRBCs for anemia and discharged to subacute rehab for daily wound care and completion of 14 day course of IV antibiotics.

# Right hip osteomyelitis/ischial decubitus ulcer/bacteremia
– Patient reporting chronic pain at sites of decubitus ulcers
– IV Ceftaroline 600 mg daily until 11/04/2021 via right arm PICC line
– daily wound care
– positioning/turning and foam pads for pressure relief
– pain management with Tylenol 650 mg q4hrs standing as well as Oxycodone 5 mg q6hrs PRN
– vital sign monitoring for fever, HR, BP, SpO2
– monitor for abdominal symptoms
– psychiatry evaluation to determine if patient understands condition and has insight into prognosis. Rediscuss surgery once evaluated.

 

# CAD, HTN, HLD
– patient reports home systolic BP highest at about 130, similar to hospital vital signs. HTN appears well-controlled, will monitor vital signs daily for trends in BP control. Patient denies chest pain, palpitations, SOB, dizziness, weakness.
– Continue Metoprolol succinate XL 50 mg daily, Atorvastatin 80 mg daily
– order CBC, CMP, Lipid panel for baseline labs and monitoring of antibiotic treatment

# DM2
– Patient reports home fingerstick range 100-140, no hypo/hyperglycemia reported in hospital. Will continue to monitor fingerstick.
– continue Humulin NPH U-100 16 units at bedtime.

# Anemia of chronic disease
– patient denies weakness, fatigue, SOB
– Ferrous sulfate 325 mg once a day
– repeat hemoglobin/hematocrit in two weeks

# Advanced Directives
– Full code

# Nutrition
– patient appears well-nourished and reports good appetite following hospital admission
– heart-healthy/diabetic diet, optimized for wound-healing and glycemic control