Rt4 mini CAT

Clinical Question: As in the past, please briefly outline the scenario and state your clinical question as concisely and specifically as possible

Scenario: Pt w/ history of Plantar fasciitis c/o heel pain worsen in the morning, and relieve throughout the day. Already taking NSAIDs but only with mild to no relief.  Considering steroid treatment. Wants to know if other available treatment options are available.

 

Question: For patients with plantar fasciitis, is platelet-rich plasma (PRP) therapy effective in pain relief when compared to steroid treatment?

PICO Question:

Identify the PICO elements – this should be a revision of whichever PICO you have already begun in a previous week

Plantar fasciitis	Platelet-rich plasma	Steroid	Pain relief
adults		Conservative treatment	Pain scale
			Quality of Life
			Safety and efficacy
			Improvement in functional restoration

 

Search Strategy:

Outline the terms used, databases or other tools used, how many articles returned, and how you selected the final articles to base your CAT on.  This will likewise be a revision and refinement of what you have already done.

Key words used: “plantar fasciitis”, “Platelet-rich plasma”, “steroid”, “pain”, “pain relief”, “functional improvement”

Pubmed:

• Platelet-rich plasma/plantar fasciitis/most recent: 65 results
• Platelet-rich plasma/plantar fasciitis/best match: 69 results
• Platelet-rich plasma/plantar fasciitis/best match/10 years: 68 results
• Platelet-rich plasma/plantar fasciitis/best match/10 years/humans/English/adult: 24 results

 

CINAHL:

• Platelet-rich plasma/plantar fasciitis/10 years: 65 results
• Platelet-rich plasma/plantar fasciitis/10 years/adults: 15 results

Cochrane Library:

• Platelet-rich plasma/plantar fasciitis/10 years: 8 results

 

How do I narrow down my articles?

• Articles are narrowed down by having the key words in the title and abstract. Then articles of the most recent and higher level of evidence will be selected. The population of study, intervention and control, outcome of the study will also need to match my PICO question.

 

Articles Chosen (3-5) for Inclusion (please copy and paste the abstract with link):

 

Platelet-rich plasma as a treatment for plantar fasciitis: A meta-analysis of randomized controlled trials.

Yang WY, Han YH, Cao XW, Pan JK, Zeng LF, Lin JT, Liu J.

2017 Nov;96(44):e8475. doi: 10.1097/MD.0000000000008475. Review.

PMID: 29095303

BACKGROUND: Recently, platelet-rich plasma (PRP) has been used as an alternative therapy for plantar fasciitis (PF) to reduce heel pain and improve functional restoration. We evaluated the current evidence concerning the efficacy and safety of PRP as a treatment for PF compared with the efficacy and safety of steroid treatments.

METHODS: Databases (PubMed, EMBASE, and The Cochrane Library) were searched from their establishment to January 30, 2017, for randomized controlled trials (RCTs) comparing PRP with steroid injections as treatments for PF. The Cochrane risk of bias (ROB) tool was used to assess the methodological quality. Outcome measurements were the visual analogue scale (VAS), Foot and Ankle Disability Index (FADI), American Orthopedic Foot and Ankle Society (AOFAS) scale, and the Roles and Maudsley score (RMS). The statistical analysis was performed with RevMan 5.3.5 software.

RESULTS: Nine RCTs (n = 430) were included in this meta-analysis. Significant differences in the VAS were not observed between the 2 groups after 4 [weighted mean difference (WMD) = 0.56, 95% confidence interval (95% CI): -1.10 to 2.23, P = .51, I = 89%] or 12 weeks of treatment (WMD = -0.49, 95% CI: -1.42 to 0.44, P = .30, I = 89%). However, PRP exhibited better efficacy than the steroid treatment after 24 weeks (WMD = -0.95, 95% CI: -1.80 to -0.11, P = .03, I = 85%). Moreover, no significant differences in the FADI, AOFAS, and RMS were observed between the 2 therapies (P > .05).

CONCLUSION: Limited evidence supports the conclusion that PRP is superior to steroid treatments for long-term pain relief; however, significant differences were not observed between short and intermediate effects. Because of the small sample size and the limited number of high-quality RCTs, additional high-quality RCTs with larger sample sizes are required to validate this result.

 —————————————————————————————————————–

Effects of platelet-rich plasma in the treatment of plantar fasciitis: A meta-analysis of randomized controlled trials.

Ling Y, Wang S.

Medicine (Baltimore). 2018 Sep;97(37):e12110. doi: 10.1097/MD.0000000000012110.

PMID: 30212938

Abstract

BACKGROUND: Plantar fasciitis is a common cause of heel pain, which often results in significant morbidity. There have been several treatment options that are used for plantar fasciitis, including nonsteroidal anti-inflammatory drugs, orthoses, physical therapy, and steroid injections.

OBJECTIVES: The aim of this meta-analysis was to compare the effects of platelet-rich plasma (PRP) and other treatments in patients with plantar fasciitis.

SEARCH METHODS: Medline, Web of Science, and Embase were systematically searched to identify relevant trials.

SELECTION CRITERIA: Randomized controlled trials (RCTs) that compared the effects of PRP and other treatments on plantar fasciitis were included.

DATA COLLECTION AND ANALYSIS: The main outcomes included changes from baseline in visual analog scale (VAS) score, American Orthopaedic Foot and Ankle Society Score (AOFAS), and Roles-Maudsley score (RMS). Results were expressed as weight mean difference (WMD) with 95% confidence interval (95% CI). The meta-analysis was performed using a fixed-effects or random-effects model according to heterogeneity.

MAIN RESULTS: Ten RCTs involving a total of 445 patients with plantar fasciitis were included. Among these studies, 9 compared PRP with steroid, and 1 compared PRP with whole blood. Four studies were categorized as being at low risk of bias, and the remaining 6 as being at unclear risk of bias. Pooled estimates suggested that PRP had greater changes in VAS and AOFAS scores than other treatments. However, it had no benefit effect in the RMS. Subgroup analysis for VAS and AOFAS showed that PRP had superior effect than other treatments at 12 months, but not at the 1, 3, 6 months. Subgroup analysis based on treatment regimens demonstrated that PRP was more effective than steroid in the change from baseline in AOFAS, but not in VAS and RMS scores.

AUTHORS’ CONCLUSION: PRP was as effective as other treatments in reducing pain and improving function in patients with plantar fasciitis. Subgroup analysis indicated that PRP had better effect than steroid in AOFAS Score and its effect was durable in a long term. However, considering the potential limitations in this study, more large-scale RCTs are needed to confirm the current findings.

—————————————————————————————————————–

Efficacy of platelet-rich plasma as conservative treatment in orthopedics: a systematic review and meta-analysis.

Franchini M, Cruciani M, Mengoli C, Marano G, Pupella S, Veropalumbo E, Masiello F, Pati I, Vaglio S, Liumbruno GM.

Blood Transfus. 2018 Nov;16(6):502-513. doi: 10.2450/2018.0111-18. Epub 2018 Sep 3. Review.

PMID: 30201082

Abstract:BACKGROUND: The aim of this systematic review and meta-analysis was to evaluate the benefit of platelet-rich plasma (PRP) in non-surgical orthopedic procedures.

MATERIAL AND METHODS: We searched the Cochrane Wounds Specialized Register, CENTRAL, MEDLINE (through PUBMED), Embase, and SCOPUS. We also searched clinical trials registries for ongoing and unpublished studies and checked reference lists to identify additional studies.

RESULTS: We found 36 randomized controlled trials (2,073 patients) that met our inclusion criteria. The included studies mostly had small numbers of participants (from 20 to 225). Twenty-eight studies included patients with lateral epicondylitis or plantar fasciitis. PRP was compared to local steroids injection (19 studies), saline injection (6 studies), autologous whole blood (4 studies), local anesthetic injection (3 studies), dry needling injection (3 studies), and to other comparators (4 studies). Primary outcomes were pain and function scores, and adverse events. On average, it is unclear whether or not use of PRP compared to controls reduces pain scores and functional score at short- (up to 3 months) and medium- (4-6 months) term follow-up. The available evidence for all the comparisons was rated as very low-quality due to inconsistency, imprecision, and risk of bias in most of the selected studies. There were no serious adverse events related to PRP injection or control treatments.

CONCLUSIONS: The results of this meta-analysis, which documents the very marginal effectiveness of PRP compared to controls, does not support the use of PRP as conservative treatment in orthopedics.

—————————————————————————————————————–Effectiveness and relevant factors of platelet-rich plasma treatment in managing plantar fasciitis: A systematic review.

Chiew SK, Ramasamy TS, Amini F.

J Res Med Sci. 2016 Jun 14;21:38. eCollection 2016. Review.

PMID: 27904584

BACKGROUND: Plantar fasciitis (PF) is a common foot complaint, affects both active sportsmen and physically inactive middle age group. It is believed that PF results from degenerative changes rather than inflammation. Platelet-rich plasma (PRP) therapy has been introduced as an alternative therapy for PF. This study is aimed to systematically review to the effectiveness and relevant factors of PRP treatment in managing PF.

MATERIALS AND METHODS: A search was conducted in electronic databases, including PubMed, Scopus, and Google Scholar using different keywords. Publications in English-language from 2010 to 2015 were included. Two reviewers extracted data from selected articles after the quality assessment was done.

RESULTS: A total of 1126 articles were retrieved, but only 12 articles met inclusion and exclusion criteria. With a total of 455 patients, a number of potentially influencing factors on the effectiveness of PRP for PF was identified. In all these studies, PRP had been injected directly into the plantar fascia, with or without ultrasound guidance. Steps from preparation to injection were found equally crucial. Amount of collected blood, types of blood anti-coagulant, methods in preparing PRP, speed, and numbers of time the blood samples were centrifuged, activating agent added to the PRP and techniques of injection, were varied between different studies. Regardless of these variations, superiority of PRP treatment compared to steroid was reported in all studies.

CONCLUSION: In conclusion, PRP therapy might provide an effective alternative to conservative management of PF with no obvious side effect or complication. The onset of action after PRP injection also greatly depended on the degree of degeneration.

Summary of the Evidence:

Author (Date)	Level of Evidence	Sample/Setting (# of subjects/ studies, cohort definition etc. )	Outcome(s) studied	Key Findings	Limitations and Biases
Article #1   Yang WY, Han YH, Cao XW, Pan JK, Zeng LF, Lin JT, Liu J. 2017 Nov	Meta-analysis of RCTs	9 RCTs with 430 participants	Pain relief, visual analogue scale (VAS), Foot and Ankle Disability Index (FADI), American Orthopedic Foot and Ankle Society scale (AOFAS), and Roles and Maudsley score (RMS)	-VAS: no significant differences were observed between the 2 groups. (WMD) = 0.56, 95% confidence interval (95% CI): -1.10 to 2.23, P = .51, I = 89%] or 12 weeks of treatment (WMD = -0.49, 95% CI: -1.42 to 0.44, P = .30, I = 89%). However, platelet-rich plasma exhibited better efficacy than the steroid treatment after 24 weeks (WMD = -0.95, 95% CI: -1.80 to -0.11, P = .03, I = 85%).   -FADI: no significant differences between the 2 groups after 12 weeks. (WMD=14.08, 95% CI: -11.57 to 39.73, P=0.28, I^2 = 99%) -AOFAS scale: no significant differences between the 2 groups after 12 weeks. (WMD=0.94, 95% CI: -5.99 to 7.86, p=0.79, I^2=81%)   -RMS: no significant differences between the 2 groups after 6 months. (RR=1.75, 95%CI: 0.27-11.38, P=0.56, I^2=90%)   -No significant difference in pain relief between platelet rich plasma for short term or intermediate term. However, platelet rich plasma displays better long-term efficacy. Platelet rich plasma and steroids have similar effects on functional improvement.	-Only 9 studies were included in the study with 430 participants. The credibility for all outcome may be limited by the small sample size. -Some of the reported results are subjective, such as VAS score. -Longest assessment period in the included studies was 48 weeks after PRP administration, unable to determine whether the issue reoccurrence 1 year after PRP treatment.
Article #2   Ling Y, Wang.S 2018 Sep	Meta-analysis of RCTs	10 RCTs with 445 patients	VAS, AOFAS, RMS	-Platelet rich plasma had a greater decrease in VAS score than placebo (WMD = -4.01, 95% CI: -5.54, -2.49; P < .001), but a comparable change with steroid (WMD = -0.47, 95% CI: -0.94, 0.01; PP=.247). – Platelet rich plasma had a significant increase in AOFAS score when compared with steroid (WMD=7.85, 95% CI: 0.48, 15.23; P = .037) or placebo (WMD = 32.7, 95% CI: 25.5, 39.89; P < .001). -Platelet rich plasma did not have an advantage effect in the decrease of RMS when compared with steroid (WMD=_0.09, 95% CI: _0.84, 0.65; P = .809) -PRP was effective at reducing pain and improving physical function -Long term PRP could improve pain and physical function, but 1 to 6 months of short term PRP could not. -PRP should be used as an alternative approach for patients with plantar fasciitis	– study was conducted based on 10 RCTs, all of which had a relatively small sample size (N<100). This might be more likely to result in an overestimation of the treatment effects compared to larger trials. – Data analysis for RMS was based on 3 RCTs, conclusion about the effects of PRP in RMS should be interpreted with caution.
Article #3   Franchini M, Cruciani M, Mengoli C, Marano G, Pupella S, Veropalumbo E, Masiello F, Pati I, Vaglio S, Liumbruno GM. 2018 Nov	Systematic review and meta-analysis.	36 RCTs with 2,073 patients	VAS, functional measurement such as AOFAS, plantar fascia thickness measured by ultrasound. Study also include VAS at 3 months (8 studies, 420 patients) and 6 months (6 studies, 300 patients)	-With steroids as control, data shows slightly better pain scores in PRP treated group at 6 months (260 patients; MD -9.47; 95% CI: -17.98/0.97; I^2=92%), but not at 3 months (8 studies, 420 patients; MD -8.95)   -Both at 3 months (178 patients) and at 6 months (218 patients), AOFAS did not change significantly between the PRP and steroid group (MD, 4.26; 95%CI： -5.96/12.47; and 4.25; 95%CI: -5.92/14.42, respectively)   -Plantar fascia thickness measured by ultrasounds: no significant difference between groups   – PRP injection may not result in lower pain and function scores   -Marginal benefit at medium term follow up (4-6 months) for VAS outcome was observed	-Were not able to determine the long-term (>12 months) effect of RPR -Lack of standardization of PRP production among different studies and limits the validity of an inter-studies comparison. – Studies mostly had small numbers of participants (from 20 to 225)
Article #4   Chiew SK, Ramasamy TS, Amini F 2016 Jun	Systemic Review (prospective cohort, RCTs, retrospective cohort)	12 articles with 445 patients	AOFAS, RMS, VAS, postinjection foot and ankle outcome scores, foot function index, and 12-item short form health survey (SF-12)	-In most of the studies, the improvement was observed during the first 3 months after injection. Significant improvement was also noted when the patient was followed up till 12 months postinjection.   -Single injections of PRP decreased pain and improves function better than a corticosteroid injection.   -No evidence of side effect or complications when PRP was used in treating PF.	-Sample size of the 12 studies ranged from 14 to 60 participants. – absence of placebo for comparison

 

Conclusion(s) Briefly summarize the conclusions of each article, then provide an overarching conclusion.

Article #1: No significant difference in pain relief between platelet rich plasma for short term or intermediate term. However, platelet rich plasma displays better long-term efficacy. Platelet rich plasma and steroids have similar effects on functional improvement.

 

Article #2: PRP was effective at reducing pain and improving physical function. Long term PRP could improve pain and physical function, but 1 to 6 months of short term PRP could not. PRP should be used as an alternative approach for patients with plantar fasciitis

Article #3: Plantar fascia thickness measured by ultrasounds: no significant difference between groups. PRP injection may not result in lower pain and function scores. Marginal benefit at medium term follow up (4-6 months) for VAS outcome was observed

 

Article #4: Improvement was observed during the first 3 months after injection. Significant improvement was also noted when the patient was followed up till 12 months post-injection. No evidence of side effect or complications when PRP was used in treating PF.

 

Overall conclusion: PRP is effective at reducing pain and improving physical function, with more significant improvement for long term compared to short term. No evidence of side effect or complication when PRP was used in treating PF. PRP has similar effects on functional improvement compared to steroid.

 

Clinical Bottom Line:

Local injection of PRP is an emerging therapeutic alternative. Therefore, number of RCTs have been done to evaluate whether the use of PRP is effective for pain relief and functional improvements for patients with plantar fasciitis. However, the effectiveness of PRP injection still remains controversial. I have found 4 articles, which all are meta-analysis/systematic reviews. These are also published very recently. However, the RCTs included in the studies are mostly small scale and not high qualitied. Benefit of PRP in the studies has shown to be effective in long term uses, but not in short term uses for plantar fasciitis. It is also shown that PRP has similar effects on functional improvement compared to steroid injection. Local injection of PRP should not be fully replaced steroid injection for the treatment of chronic plantar fasciitis. More well-designed RCT studies with larger samples and higher quality will be needed to prove the effects of PRP with steroid treatment.

 

Rotation 4- LTC Reflection

 

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

The knowledge that I’ve gained here will be applicable in other rotations because the geriatric population continues to grow. Not only that I will see geriatric patients in long term care, but also in my future rotations such as emergency medicine, internal medicine, or even psychiatry. Dealing with geriatric population and interviewing them can be very different. They will have a long list of past medical/surgical history and medication. I learn how to be more cautious about polypharmacy, drug interaction and drug contraindication. For example, many elderly with end stage renal disease requires dialysis, and we have to be careful about prescribing drugs that are nephrotoxic or adjusting the dosage for them. In addition, elderly are more prone to falls with weakness and difficulty seeing when they age. Therefore, it is important to assess fall in elderly because they may lead to fracture and brain bleed. These types of patients can be seen in all my other rotations as well as my future career as a PA.

 

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

For the following rotations, I would like to continue to work on my procedure log book. There are still a lot of other clinical skills that I would like to practice.  I want to have the opportunity to practice and learn as many clinical skills as possible. My action plan to accomplish that is letting my preceptors know that I am really interested in practicing my clinical skills and ask if they are willing to teach me when there is a chance.

 

 

How your perspective may have changed as a result of this rotation (e.g. elderly patients, kids, IV drug users, etc). 

My perspective has changed as a result of this rotation for elderly patients. I have learned that communicating with elderly patients may be different and requires more time compared to the younger population. To communicated effective with elderly, I will have to plan more time instead of appearing rushed or uninterested. Because they will sense it and shut down. It is also important to sit face to face because some older patient may have vision and hearing loss. Sitting in front of them and maintaining eye contacts will allow them to read your lips and also providing them with undivided attention. Another thing about interviewing elderly patients is that I will speak slowly, clearly, and loudly. This will help them to take in the information slowly.

 

Types of patients you found challenging in this rotation and what you learned about dealing with them

Geriatric patients are overall challenging in this rotation.  I have learned how to communicate with them more effectively, especially those that are not as educated. They will require more time for explaining the information. In order to communicate with them effectively, I will try to stick to one topic at a time because overload of information can confuse patients. I will also simplify instructions and write the instructions in a list on a paper. Patients can easily check off each item with such a list. Charts and pictures are also great visual aid that will help patients better understand their condition and treatment.

 

Rotation 4 Site Evaluation Summary

 

During my site evaluations for this rotation, I started by presenting my H&P. My case was about how a NG tube failed to treat a small bowel obstruction. A diagnostic exploratory laparotomy had to be done and revealed a foreign body. Then I presented an article about how effective is ultrasound in diagnosing small bowel obstruction when compared to the gold standard CT scan. My site evaluator also went over the important points for small bowel obstruction after the presentation of my case, which I found to be very helpful. For example, the most common causes of SBO, the classic clinical presentation, diagnostic imaging, and treatment. I also got quizzed on my pharm cards as well as other students’ pharm cards. Lastly, we reviewed the procedure book. My site evaluator did not comment much on the way I presented my H&Ps, articles, and pharm cards. However, he gave a lot of useful comments on the way that the patient should had been evaluated. This will be very beneficial and applicable to my future rotations when I am generating a list of differential and evaluation for the patients.

SBO article

Utilization of ultrasound for the evaluation of small bowel obstruction: A systematic review and meta-analysis.

Gottlieb M¹, Peksa GD², Pandurangadu AV², Nakitende D², Takhar S³, Seethala RR³.

Am J Emerg Med. 2018 Feb;36(2):234-242. doi: 10.1016/j.ajem.2017.07.085. Epub 2017 Jul 29.

 

Article Summary:

• SBO is a common presentation in the ED and CT is often used to confirm diagnosis. However, this modality is expensive, exposes patients to radiation, may lead to time delays, and is not universally available. Therefore, this study is conducted to determine the diagnostic accuracy of ultrasound to detect SBO.
• The reasons that I would choose this study are that it is a systematic review and meta-analysis, and it is published recently in 2018 by the American Journal of Emergency Medicine.
• 11 studies comprising 1178 total patients were included in the study. Overall, ultrasound was found to be 92.4% sensitive (95% CI 89.0% to 94.7%) and 96.6% specific (95% CI 88.4% to 99.1%) with a positive likelihood ratio of 27.5 (95% CI 7.7 to 98.4) and a negative likelihood ratio of 0.08 (95% CI 0.06 to 0.11).
• In conclusion, ultrasound is suggested to be a valuable tool in the diagnosis of SBO with a sensitivity and specificity comparable to that of CT. Ultrasound appears better than MRI and radiography. It may save time and radiation exposure, while also allowing for serial examination of patients to assess for resolution of the SBO. It can also be performed at bedside allowing for rapid diagnosis, consultation, and intervention. It is also beneficial in settings with limited or no access to CT.

 

• Limitations:
• All the studies included are prospective, observational studies. Lack of RCTs
• Difference in sonographer might also limited the data
• Limited data in the pediatric population

 

• Future studies:
• Larger patient groups
• More studies focused in the ED settings
• Comparisons of probe choices
• Inclusion of more pediatric patients.

HP1

Full H&P

Rotation 4: LTC

Ling Yi Mei

Note: exams in light grey shade are NOT performed

Identification:

Patient’s name: SF

Age: 80

Gender: M

Race: Asian

Location: Gouverneur Hospital

Date: 4/29/19

Informant: self, reliable

CC: “abdominal pain and vomiting” x 2 days

HPI:

80 y.o M with PMHx of HTN, HLD, chronic LBP, and a PSH of appendectomy was admitted to Gouverneur Skilled Nursing Facility on 4/26/19 to receive skilled nursing w/ wound care along with PT/OT services to achieve highest functional status in activities of daily living. He was transferred from NY Pres Low Manhattan where he was admitted on 4/15/19 for intestinal bowel obstruction. Pt initially presented to ED with abd pain and vomiting x 2 days. Small bowel obstruction did not resolve with NG tube placement. Diagnostic laparoscopic followed by exploratory laparotomy revealed small bowel foreign body which was removed on 4/17. Pt tolerated the procedure well without major complications. Umbilical incision was noted to be mild erythematous for which pt was started on Keflex. On the day of discharge, pt was sent 6 days of Keflex to be completed at SAR. Pt was urinating, ambulating, tolerating diet, and pain was well controlled. Pt requires extensive assist in most ADL’s with supervision for eating.

PMH:

HTN

HLD

Chronic LBP

Past Surgical History:

Appendectomy

 

Medications:

Meloxicam 15mg PO daily

Keflex 500mg PO BID x 6 days

Multivitamin daily supplement

Amlodipine 5mg PO daily

Calcium 600 1 tab PO BID

 

Allergies:

NKDA

Family History:

Denies having children

Others unable to obtain from patient.

Social History:

Tobacco use: quit 5 yrs ago- smoked cig 1 ppdx 50+ years

Alcohol use: quit 5 yrs ago – drank a shot a day

Drug use: no

Lives at home with his wife. Retired restaurant worker.

ROS:

General: Patient reports, Patient denies recent weight loss or weight gain, loss of appetite, fever, chill or night sweats

Positive: generalized weakness and fatigue

Skin, Hair, Nails: Patient denies any changes of texture, excessive dryness or sweating, discolorations, pigmentations, moles, rashes, pruritus, or changes in hair condition

Head: Patient denies headache, vertigo, head trauma, or fracture

Eyes: Patient denies visual disturbance, lacrimation, photophobia, pruritus, or last eye exam

Ears: Patient denies deafness, pain, discharge, tinnitus

Nose/Sinuses: Patient denies discharge, epistaxis, or obstruction

Mouth and throat: Patient denies bleeding gums, sore tongue, sore throat, mouth ulcers or last dental exam

Neck: Patient denies localized swelling or lumps, stiffness or decreased range of motion

Pulmonary System: Patient denies SOB, DOE, cough, wheezing, hemoptysis, cyanosis, orthopnea, paroxysmal nocturnal dyspnea

Cardiovascular System: Patient denies chest pain, palpitations, edema, syncope, or known heart murmur

Gastrointestinal System: Patient denies changes in appetite, intolerance to specific foods, nausea, vomiting, dysphagia, pyrosis, flatulence, eructation, diarrhea, jaundice, change in bowel habits, hemorrhoids, constipation, rectal bleeding, blood in stool

Positive: abdominal pain. Colonoscopy done last year: negative

Genitourinary System: Patient denies changes in frequency, nocturia, urgency, oliguria, polyuria, dysuria, change in color of urine, incontinence, awakening at night to urinate, or pain

Male ONLY: denies hesitancy, dribbling or last prostate exam

Sexual history in not in social history: Pt denies sexually active

Nervous System: Patient denies seizures, headache, loss of consciousness, sensory disturbances, numbness, paresthesia, dysesthesias, ataxia, loss of strength, change in cognition, mental status, memory, or weakness

Musculoskeletal System: Patient denies muscle or joint pain, deformity or swelling, redness, arthritis

Peripheral System: patient denies intermittent claudication, coldness or trophic changes, varicose veins, peripheral edema, or color changes

Hematological System: Patient denies anemia, easy bruising or bleeding, or lymph node enlargement

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

Psychiatric: Patient denies depression, sadness, feeling of helplessness, hopelessness, lack of interest in usual activities, anxiety, obsessive or compulsive disorder, seen a mental health professional, or use medications

 

Physical Examination:

General 80 years old male is alert and cooperative. He is well dressed and doesn’t appear to be distressed. Neatly groomed, looks younger than his stated age of 80 years. Well developed.

Vital Signs:

BP (seated): 131/87

HR: 98 BMP, regular

RR:  18,not labored

Temp: 97.7 F oral

O2 sat: 98% room air

Skin: Warm & moist, good turgor. Nonicteric, no lesions noted, no scars, tattoos.

Hair: Average quantity and distribution

Nails: No clubbing, capillary refill <2 seconds throughout.

Head: Normocephalic, atraumatic, non-tender to palpation throughout

Eyes: Symmetrical OU; no strabismus, exophthalmos or ptosis; sclera white; conjunctiva & cornea clear. Visual acuity with glasses 20/20 OS, 20/20 OD, 20/20 OU. Visual fields full OU. PERRLA (old people do not accommodate), EOMs full with no nystagmus. Fundoscopy – Red reflex intact OU. Cup:Disk < 0.5 OU, no AV nicking, papilledema, hemorrhage, exudate, cotton wool spots, or neovascularization OU

Ears: Symmetrical and normal size. No lesions, masses, trauma on external ears. No discharge, foreign bodies in external auditory canals AU. TM’s pearly white, cone of light at 4 o’clock in right ear, 7 o’clock in the left ear. Auditory acuity intact to whispered voice AU. Weber midline, and Rinne reveals AC>BC AU

Nose: Symmetrical with no masses, lesions, deformities, or trauma. Nasal mucosa pink, no discharge or foreign bodies. Anterior septum deviated to left, no lesions, deformities, injection perforation

Sinuses: Nontender to palpation and percussion over bilateral frontal, ethmoid and maxillary sinuses

Lips: Pink, dry, no cyanosis or lesions

Mucosa: Light pink, dry, no masses, lesions, or leukoplakia

Palate: Pink, hydrated. Palate intact with no lesions, masses, scars, nontender to palpation, continuity intact

Teeth: Missing a few teeth on the left sides, not wearing dentures

Gingivae: Pink, no hyperplasia, masses, lesions, erythema, or discharge

Tongue: Pink, no masses, lesions, or deviations noted

Oropharynx: Hydrated, no injection, exudate, masses, lesions, or foreign body. Tonsil present with no injection or extrudate, uvula light pink, no edema or lesions

Neck: No masses, lesions or scars. Trachea midline, pulsation noted. Supple nontender to palpation. 2+ carotid pulses, no thrills, bruits bilaterally. No palatable adenopathy

Thyroid: Nontender, no palpable masses, no thyromegaly, no bruits

Chest: Symmetrical, lat to AP diameter 2:1, no deformities, no trauma. Respirations unlabored. Nontender to palpation

Lungs: Clear to auscultation and percussion bilaterally. Chest expansion and diaphragmatic excursion symmetrical. Tactile fremitus intact throughout. No wheezing, crackles, rales

Heart: S1, S2 without murmur, no gallops, S3 or S4. RRR. No JVD. Carotid pulse are 2+ bilaterally without bruits

Abdomen: Flat, symmetrical, striae, caput medusae or abnormal pulsations. Bowel sounds in all 4 quadrants. No bruits. Tympany to percussion throughout. No organomegaly, guarding, or rebound tenderness. No CVAT bilaterally

Positive: mild tenderness upon palpation. Mid umbilical incision noted, with redness and warmth.

Male genitalia and hernia: Circumcised male. No penile discharge or lesions. No scrotal swelling or discoloration. Testes Descended bilaterally, smooth and without masses. Epididymis nontender. No inguinal or femoral hernias noted

Anus, rectum, and prostate: No perirectal lesions or fissures. External sphincter tone intact. Rectal vault without masses. Prostate smooth and nontender with palpable median sulcus (Or in a female, uterine cervix nontender.) Stool brown and Hemoccult negative

Rectal: No external hemorrhoids, skin tags, ulcers, sinus tracts, anal fissures, inflammation or excoriations. Good anal sphincter tone. No masses or tenderness. Trace brown stool present in vault. FOB negative

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

Neurological:

Mental status: Alert and oriented to person, place and time. Memory and attention intact. Receptive and expressive abilities intact. Thought coherent. No dysarthria, dysphonia or aphasia noted

Cranial nerve:

I – Intact no anosmia.

II- VA 20/20 bilaterally. Visual fields by confrontation full. Fundoscopic + red light reflex OS/OD, discs yellow with sharp margins. No AV nicking, hemorrhages or papilledema noted.

III-IV-VI- PERRLA, EOM intact without nystagmus.

V- Facial sensation intact, strength good. Corneal reflex intact bilaterally.

VII- Facial movements symmetrical and without weakness.

VIII- Hearing grossly intact to whispered voice bilaterally. Weber midline. Rinne AC>BC.

IX-X-XII- Swallowing and gag reflex intact. Uvula elevates midline. Tongue movement intact.

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

Motor/Cerebellar: Full active and passive ROM of all extremities without rigidity or spasticity. Normal muscle bulk and tone. No atrophy, tics, tremors or fasciculations. Strength equal and appropriate for age bilaterally (5/5 throughout). No Pronator Drift. Gait normal with no ataxia. Tandem walking and hopping show balance intact. Coordination by RAM and point to point intact bilaterally. Romberg negative

Sensory: Intact to light touch, sharp/dull, vibratory, proprioception, point localization, extinction, stereognosis and graphesthesia testing bilaterally

Reflexes                      R         L                                              R         L

Brachioradialis 2+        2+                    Patellar 2+        2+

Triceps                        2+        2+                    Achilles           2+        2+

Biceps                         2+        2+                    Babinski          neg      neg

Abdominal                  2+/2+  2+/2+              Clonus             negative

Meningeal signs: No nuchal rigidity noted. Brudzinski’s and Kernig’s signs negative

Musculoskeletal System:

Upper extremities and lower extremities: No soft tissue swelling, erythema, ecchymosis, atrophy or deformities in bilateral upper and lower extremities. Nontender to palpation, no crepitus noted throughout. Full range of motion of all upper and lower extremities bilaterally. No spinal deformities

Pertinent Diagnostic studies:

CT abd/pelvis 4/15: partial small bowel obstruction with transition point in the RUQ with fecalization of the small bowel in this this region and collapse of distal small bowel loops. Small bowel distention measures up to 3.3 cm. Trace ascites, non-specific.

 

Assessment:

80 y.o male with PMHx of HTN/HLD, chronic back pain, and a PSHx of appendectomy was admitted to Gouverneur Skilled Nursing Facility after transferring from NY Pres where he was admitted for small bowel obstruction and s/p exploratory laparotomy and foreign body removal.

Differential Diagnosis:

Small bowel obstruction

Diverticulitis

Gastroenteritis

GERD/gastritis

Mesenteric Ischemia

Plan:

1. Continue Daily Multidisciplinary rehabilitation

• Monitor pt, V/S, assist with ADLs, and ambulation
• Rehab PT/OT
• Pressure ulcer prevention: pressure reducing device for chair and bed; turning/repositioning program
• Fall precaution
• DVT prophylaxis
• Aspiration precaution
• Use Bell for safety and help when needed-keep within reach
• Bed at lowest position
• Anticipate and meet pt needs
• Constipation prophylaxis

1. Small bowel obstruction and removal of foreign body

• Wound care: allow water to run over area, do not scrub
• Progress activity as tolerated
• f/u with general surgery in 1-2 weeks
• f/u with PCP in 1 week

1. Umbilical incision cellulitis

• Continue Keflex 500mg PO BID for 6 days from 4/26- 5/1

1. HTN/HLD

• Continue with amlodipine
• Monitor BP and assessment
• f/u lab

1. Chronic LBP

• Continue with meloxicam 15 mg daily.

 

LTC Typhon