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164 pages, Paperback
First published January 1, 1997
Exactly How [Dark] can Writing Get? — Elkins
Imaginary History and Physical Note
I had the pleasure to meet and assess @NAME@, who is apleasantgentleman with multiple chronic medical conditions and significant disease burden (Karnofsky Performance Score 30) who presents with frequent bloody bowel movements and BRBPR. Loose stools progressive over several days associated with abdominal discomfort which patient reports as mild with no modifying factors. Patient reports poor diet consisting almost exclusively of meat products, and denies recent dietary changes. Patient does not take any fiber or dietary supplements.
Family History: Reviewed and not pertinent
Social History: Retired hospital administrator (?). Lives in upstairs apartment with wife who provides all care. Confined to bathroom "by choice" (review this, concern for spousal abuse). No VNA or outside nursing assistance.
Review of Systems:
GEN: Fatigue, Denies fever, Denies weight loss; ENDO: Fatigue, Cold intolerance; HEENT: "Rotting gums", Denies gum/tooth pain, Denies pain with mastication; PULM: Denies cough, Denies SOB; CV: Denies CP, Denies Palpitations, Denies Syncope; GI: Frequent loose bowel movements, BRPBR, Denies N/V, Denies dysphagia, Denies odynophagia; GU: Chronic indwelling urinary catheter, chronic loss of sensation to penis; EXT: Weakness, Denies LE edema; NEURO: Complete loss of LE sensation and loss of sensation to hands, Denies HA; PSYCH: Denies SI/HI
Physical Exam:
GEN: Seated in wheelchair, mild distress; HEENT: Blindness, b/l lens opacification, Edentulous, dry mucous membranes, bolus of chewing gum present in oral cavity; PULM: poor inspiratory effort with impaired air entry, end-expiratory wheeze; CV: RRR, no MRG; GI: Obese, mildly distended, tender, Stool containment system in place (?!); GU: Urinary catheter in place, concentrated urine EXT: Wasting of b/l LE; NEURO: Poor cooperation on exam. 1/5 strength B/L LE. Loss of sensation to b/l hips, chronic venous statis changes with numerous small ulcerations. Subjective loss of sensation to b/l wrists, though able to easily unwrap chewing gum wrappers throughout exam.; PSYCH: Alert and oriented x3/4 (oriented to self, place, situation, NOT year), thoughts linear, goal-directed, mildly tangential, content of thoughts upset and resentful
Problem History9D90.6 Blindness; laterality: XK9J Bilateral; associated with: 9D96 Impairment of uncorrected visual acuity
8C03.3 Polyneuropathy in nutritional deficiency
GA90 Hyperplasia of prostate
MF50.3 Retention of urine
QF23 Difficulty or need for assistance with mobility
QF27 Difficulty or need for assistance at home and no other household member able to render care
HA40 Aetiological considerations in sexual dysfunctions and sexual pain disorders
HA00.2 Hypoactive sexual desire dysfunction, acquired, generalised
Associated with HA40.4 Aetiological considerations associated with relationship factors
6D70.2 Delirium due to multiple etiological factors
Assessment:
@NAME@'s loose and bloody BM's in the setting of poor diet and chronic constipation with mild impairment of mental status is concerning for sepsis secondary to diverticulitis. Differential diagnosis also includes GI bleed, Catheter-associated urosepsis, malignancy, and superficial erosion of anorectal epithelium from stool containment system for which there is no active indication. Patient currently unable to manage activities of daily living at home with evidence of poor diet and reported confinement concerning for spousal and elder abuse, and will require long-term placement. Patient will be transported by ambulance from clinic to ED for further evaluation. Although septicemia is life threatening, patient's overall presentation is encouraging, and the absence of obvious terminal pathology suggests potential for significant longevity pending recovery from acute illness and appropriate home care. Detailed plan as below:
#NEURO
#Peripheral Neuropathy
Likely secondary to poor nutrition, though also concerned about distant cauda equina in setting of possible incontinence
-Thiamine, B12, Folate levels obtained
-Thiamine, B12, Folate, and multivitamin recommended.
-Dietary supplement with Ensure TID
#HEENT
#Edentulous Oral Cavity
Does not have dentures at home
-Referral to dentist
#Blindness
#c/f Retinal Degeneration
#B/l Cataracts
-Encourage verbal communication
-Delirium precautions
#CV
#Chronic Venous Stasis Changes
-Wound care for leg wounds
#Concern for heart failure
-TTE
#GI
#Concern for diverticulitis
-Recommend CT Abdomen/Pelvis for evaluation of suspected diverticulitis
-Recommend removal of stool containment system, no current medical indication
#Concern for GI bleed
Also long overdue for screening colonoscopy
-CBC
-Nil Per Os
-Proton pump inhibitor IV twice daily
-GI consult for EGD/Colonoscopy pending CT A/P
#RENAL/ENDO
#Concern for Acute Kidney Injury
Reports only drinking warm soda
-BMP
-Recommend initiation of maintenance fluids while NPO
#Concern for hypothyroidism
-TSH, T4
#GU
#Concern for catheter-associated UTI
#BPH
-Urinary catheter removed and replaced
-Urinalysis sent (catheter source)
#ID
#Concern for Sepsis
-Blood cultures x2, CXR, UA as above
-Cefepime/Flagyl, avoiding vanc/zosyn in setting of unknown renal function
-MRSA nares
#Concern for Sacral wound
Patient with remarkably intact skin given reported absence of movement
-Wound care consult
-Turns Every 2 hours
-apply Mepilex
#PSYCH/SOC
#Concern for MDD
-Recommend initiation of SSRI
#Concern for Elderly abuse/Spousal Abuse
-Social work notified, requires further evaluation and likely placement in long-term care facility
Greater than 50 percent of this visit was spent in direct counseling, coordination, and patient care
@SIGNATURE@
@DATE@
CPT Billing Code 99204 (New Patient, Level 4 decision making)
Procedure Code 57102 (Replacement of indwelling urinary catheter)
"Is this tight [dark] enough for you?" — Pynchon