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C.W. 78yo, African male S. CC- Restless HPI- The patient’s son is concerned because the patient lives alone and he has been acting angry, restless and hasn't slept in weeks. The patient expresses himself by periodically yelling, hyper-verbal, and obnoxious. He is unkempt and smells strongly of urine, alcohol, body odor and has an unsteady gait. The patient was medically separated from the military due to mental health issues after 2 years, which ended in 1947. He typically seeks no acute or preventative medical care. He was treated by a psychiatrist previously, but he did not like taking the prescribed medications so he stopped taking them and did not keep any further psychiatric appointments. O- Hasn't slept in weeks. L- Generalized. Emotional. D- No information given. C- Angry, restless, yelling, hyper-verbal, obnoxious A- No information given. R- No information given. T- No information given. PMH- Denies previous diagnoses. Admits to being diagnosed with paranoid schizophrenia by a psychiatrist, but denies having any psychiatric problems. He stopped taking all medications prescribed. Last Colonoscopy was 2012-normal. Last dilated retinal and glaucoma exam was
Current medications- Denies prescription medications, over the counter medication, herbal therapies or vitamins. Surgeries- Denies surgeries Allergies- NKA Vaccine history- Flu vaccine: never given, Pneumovax: never given, Tetanus: never given, Herpes zoster: never given. Social history- Patient admits to smoking cigarettes and cigars. He estimates that he smokes about 1 pack of cigarettes daily for the last 40 years, and 2 cigars each week for the last 30 years. He states that he drinks a 24 ounce bottle of beer 4-6 times a week. He denies drinking
wine or hard liquor. He does admit to smoking marijuana on occasion but does not use other recreational drugs. Patient denies falling. He does not use any assistive devices for ambulation or balance. He currently lives alone. He has been married and divorced three times over the years. Family history- Reports no significant family history ROS- Constitutional- Reported by son “he has been angry, restless and hasn’t slept in weeks”. HEENT- no information given Skin- scrapes on forearms Cardiovascular- no information given Respiratory- productive cough with white sputum. Denies hemoptysis Gastrointestinal- no information given Neurological- unsteady gait, denies falling Psychiatric- He answers “No” to the PHQ-2 screening questions. O. Vitals- Height: 5’8” Weight: 154 pounds BMI: 23.4 BP: 132/76 P: 76 regular R: 16 Physical Exam- HEENT: Normocephalic, symmetric. PERRLA, EOMI, no cataracts noted; poor dentition. NECK: Neck supple; non-palpable lymph nodes; no carotid bruits. LUNGS: Respirations are unlabored, decreased breath sounds and crackles at the bases bilaterally. Prolonged expiratory phase throughout lung fields, inspiratory wheezes and a productive cough of cloudy white sputum. HEART: RRR with regular without S3, S4, murmurs or rubs. ABDOMEN: Round, firm abdomen; active bowel sounds; non-tender. NEUROLOGIC: Unsteady gait, swaying while standing during periods of agitation. Achilles reflexes are present bilaterally. Strength is equal but decreased in the upper and lower extremities bilaterally.
Diagnostic tests- CXR (r/o Pulmonary disease, infection, heart failure, cardiomegaly), baseline pulse ox (observe oxygen saturation). EKG (annual checkup), Troponin (r/o MI), CBC (r/o anemia or infectious process), sputum culture (r/o infection), CMP (r/o renal insufficiency, electrolyte imbalance, liver function), Lipid panel (increased risk factors), TSH (thyroid disorder), UA (r/o UTI). (Fenstermacher & Hudson, 2016) Peak flow measurement and pulmonary function test (assess respiratory compliance). (Goroll & Mulley, 2014) C-reactive protein levels, lactate, fecal occult, CT of abdomen and pelvis are appropriate to rule out gastrointestinal diseases due to his distended and firm abdomen (Gaddey & Holder, 2014). Elevated c-reactive protein level or erythrocyte sedimentation rate suggests RA (Wasserman, 2011). Rx- Pending the UA and CBC results the patient may need to be treated for a UTI due to his mental status and urinary incontinence (Fenstermacher & Hudson, 2016). Tiotropium inhaled 18mcg/cap DPI Sig: 2 puffs (1 cap) inhaled daily Disp: # 2, 5 refills (Fenstermacher & Hudson, 2016). (Epocrates, 2015). Albuterol inhaled 90 micrograms Sig: 1-2 puffs every 20 minutes for up to 2 hours or until clinical improvement. Then use every 4-6 hours as needed for shortness of breath or wheezing. Disp: # 2, 5 refills (Fenstermacher & Hudson, 2016). (Epocrates, 2015). In office treatment: Albuterol inhaled 5mg nebulized every 20 minutes until symptom improve (Fenstermacher & Hudson, 2016). (Epocrates, 2015). OTC- Acetaminophen 500mg tablet Sig: 1-2 tablets PO every 8 hours as needed for joint pain. Max 6 tabs/24hours (Fenstermacher & Hudson, 2016). (Epocrates, 2015). If admitted to the hospital: Clinical Institute Withdrawal Assessment for Alcohol (CIWA Scale) used for the assessment and management of alcohol withdrawal. Each item on the scale is scored independently, and the summation of the scores yields an aggregate value that correlates to the severity of alcohol
withdrawal, with ranges of scores designed to prompt specific management decisions such as the administration of benzodiazepines. The maximum score is 67; Mild alcohol withdrawal is defined with a score less than or equal to 15, moderate with scores of 16 to 20, and severe with any score greater than 20. The ten items evaluated on the scale are common symptoms and signs of alcohol withdrawal. (Stuppaeck & Barnas, 1994) Administer the CIWA-Ar every hour to assess the patient’s need for medication. Administer one of the following medications every hour when the CIWA-Ar score is at least 8 to 10 points: Chlordiazepoxide (Librium), 50 to 100 mg, or Diazepam (Valium), 10 to 20 mg, or Lorazepam (Ativan), 2 to 4 mg. (Bayard, Mcintlyre, Hill, & Woodside, 2004) Education- Manic episodes are clinically significant changes in mood, behavior, energy and sleep. Symptoms include restlessness, inappropriate and loud speech, irritability, racing thoughts and poor concentration. The patient may need inpatient therapy and a referral to a psychiatrist for initial treatment and mood stabilization. (Fenstermacher & Hudson, 2016) A pulmonary function test would help determine how well your lungs function. With that information we could formulate a pharmacological plan for your shortness of breath and exercise intolerance. Smoking cessation reduces the risk of progression. Due to your pulmonary status it is very important you keep up on your flu and pneumonia vaccines. (Fenstermacher & Hudson,
Osteoarthritis is noninflammatory degenerative changes that occur to the joints. The crepitus in your knees and the Heberden’s nodes on your fingers are a sign of osteoarthritis. For acute pain you can rest the joints, resume ROM with exercise, especially aquatic exercise for therapy. (Fenstermacher & Hudson, 2016) Referrals- I would recommend admitting the patient to the hospital for treatment of is manic behavior. If the son feels he is a threat to himself or others he may need to be baker acted in order to get immediate treatment. Referral to a psychiatrist would be appropriate. (Fenstermacher & Hudson, 2016) Pulmonologist for management and maintenance of COPD (Fenstermacher & Hudson, 2016). Depending on the results of his CT and labs it may be appropriate to refer him to a gastroenterologist for colonoscopy and management (Wilkins, Embry & George, 2013). Follow up- If admitted to the hospital follow up would be the next day for inpatient follow up. If not admitted follow up in 48 hours to evaluate respiratory status; discuss lab results and possible medication regimen. References
