Example H&P

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Arkansas State University, Main Campus *

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Medicine

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Apr 3, 2024

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HISTORY AND PHYSICAL Date: 08/28/2018 DEMOGRAPHICS: Name: TW Age: 57 Gender: F Status: INPT/HOSPITAL PCP: William Hurst, DO Insurance: Medicaid CC: “I just want to see him again (deceased boyfriend).” Presents with AMS, jaundice, swelling per boyfriend. Source/Reliability: Patient – not a reliable historian; lethargic and difficult to keep awake for conversation. Boyfriend present in room – he providers some of her medical history and aids in ROS. Most of patient’s medical history is obtained from EMR. HISTORY OF PRESENT ILLNESS (HPI) : TW is a 57-year-old Caucasian female with known history of depression, alcohol abuse, methamphetamine abuse, THC abuse. She presented to the ER after a friend reportedly called EMS due to increased swelling and worsening jaundice. Upon arrival, the patient was lethargic, difficult to keep awake, severely jaundiced. She has no known previous history of cirrhosis, although per boyfriend at bedside was admitted to a hospital approximately 3 weeks ago for abdominal pain and jaundice and at that time had a CT which they were told was abnormal. However, she left that hospital against medical advice and was not placed on any medications. She was questioned about suicidal ideation given her statement she wanted to see her deceased boyfriend, but voiced no suicidal ideation. She was admitted to the ICU for suspected cirrhosis. Since that time, she has had a toxicology screen positive for methamphetamine and benzodiazepines. Total bili 17.7, AST 83, ALT 30, alkaline phosphatase 210, WBC 19.2 with left shift and 7% bands, ammonia 55, lipase 24, INR 2.1, PTT 44.4. She has had US guided therapeutic paracentesis with 6700 cc fluid of serous fluid removed. Although a previous CT is not available for my review, it was apparently abnormal and suggestive of cirrhosis of the liver. She also had an abnormal UA as noted below. The patient has been treated with IV Rocephin 1 gram, lactulose 20 grams PO TID, Xifaxin 40 mg TID. She has also been started on spironolactone for fluid management as well as blood pressure management. She has been on seizure precautions due to potential for withdrawal, with Ativan PRN and Librium 5 mg TID, as well as replacing thiamine and folate. PAST MEDICAL HISTORY (PMH) : Depression F33.9 dx: 2017 Alcohol dependence F10.29 dx: 2017 PAST SURGICAL HISTORY (PSH) : Bilateral L4-L5 hemi laminectomy with removal of synovial cyst (2014) Cholecystectomy 2012 Tubal ligation 2012 MEDICATIONS : Lactulose 20 grams TID for treatment of hepatic encephalopathy and lowering of ammonia levels Xifaxin 400 mg TID for treatment of hepatic encephalopathy and lowering of ammonia levels Rocephin 1 gram IV daily for treatment of UTI Librium 5 mg TID for DT prophylaxis Potassium chloride 20 mEq IV PRN per protocol for electrolyte replacement Spironolactone 25 mg daily for diuresis/volume management ALLERGIES : Codeine – dizziness and weakness FAMILY HISTORY : Father – Unknown Mother – Deceased age 69, unknown medical history Paternal grandparents – deceased, age unknown, unknown medical history Maternal grandparents – deceased, age unknown, unknown medical history Children – 1 son 32, good health SOCIAL HISTORY:

Marital status: Single Children: 1 son Living arrangements: Lives with son Tobacco: 40 pack-year history of smoking ETOH: Positive – patient states only started drinking approx. 3 months ago when previous boyfriend died in Tulsa. However, EMR documents previous use with daily small bottle of whiskey in 04/2017. Boyfriend at bedside states she drinks approx. 1 pint of whiskey every day between the two of them, unknown onset of her drinking. Illicit drug use: Positive for methamphetamine and THC abuse in 2016, 2017. Caffeine use: Unknown Occupation: Disabled Advised smoking/drug cessation: Yes, however, patient somnolent during visit. Discussed importance of smoking, drug and alcohol cessation and the repercussions of continued use with patient’s son and boyfriend. Recent travel outside US? No PREVENTION: Immunizations: Flu: Unknown Pneumonia: Never Sunscreen: Unknown use Last wellness exam: Unknown; patient was last seen in hospital 3 weeks ago due to jaundice and abdominal pain, but left the ER against medical advice Mammogram: Never Pelvic exam: Unknown; patient had tubal ligation in the past Prostate exam: N/A Colonoscopy: Never REVIEW OF SYSTEMS: ***PLEASE NOTE: ROS is limited due to patient’s mental status and low level of participation during exam*** GENERAL: Denies fever, chills, fatigue SKIN, HAIR, NAILS: Denies rashes, sores, itching HEAD: Denies headaches, syncope EYES: Denies vision problems, corrective lenses EARS: Denies hearing loss, pain, tinnitus NOSE: Denies congestion, discharge MOUTH & THROAT: Denies sore throat RESPIRATORY: Denies dyspnea, SOB, cough, sputum CARDIOVASCULAR: Denies chest pain, SOB, dyspnea GASTROINTESTINAL: Generalized abdominal swelling, intermittent abdominal pain, jaundice Denies n/v/d/c. GENITOURINARY: Denies pain, burning with urination, hematuria HEMATOLOGIC: Fatigue, Denies transfusion, bleeding, or clotting disorders. NEUROLOGIC: LOC intermittent with ETOH intake, tremors associated with ETOH withdrawal. Difficulty with coordination. Denies CNS disease PSYCHIATRIC: Hx of depression. Denies suicidal thoughts, irritability PHYSICAL EXAM : VITAL SIGNS: Temp: 97.4 F BP: 102/69 HR: 66 bpm RR: 16 O2 sat: 97% on 2 L NC Height: Weight: BMI: Pain: 0 GENERAL: No acute distress . She is oriented to person, place and year. Somnolent and does not offer much conversation. Remains severely jaundiced. Will answer brief questions with a yes or no but does not remain engaged in conversation. Will open eyes but does not always make eye contact. SKIN/HAIR/NAILS: Jaundiced . No lesions noted. No cyanosis, bruising or masses. Warm, dry, smooth. Hair evenly/symmetrically distributed on body. HEENT: Head – No lesions or masses. Hair is oily, evenly distributed. Symmetrical facial movements (CN VII). TMJ moves smoothly with no crepitus. Unable to assess CN V due to patient’s mental status. Eyes – Lids, lashes, eyebrows equal bilaterally with even hair distribution. Orbits non-tender. Conjunctiva pink, sclera white. Pupils size 3 mm. PERRL with direct and consensual reaction light. Unable to assess for accommodation, Visual fields or EOMS due to mental status (CN II, III, IV and VI). Lens is clear, red reflex present, optical disk creamy pink with sharp margins. No macular or retinal changes. Retinal vessels decrease in caliber toward periphery.

Ears – Auditory canal w/ no drainage, redness or swelling. Tympanic membranes pearly grey, intact with clear cone of light; handle of malleus and umbo visible without redness bilaterally. No retraction or bulging. Hears normal conversation, does not respond to whisper. Unable to assess Weber, Rinne (CN VIII). Nose – Midline; nostrils patent. Inferior turbinates moist, no exudate noted. Mouth/Throat – Lips smooth, yellowed , no lesions. Oral mucous membranes moist, no lesions. Posterior pharyngeal wall without redness, no lesions. Unable to assess CN XII, IX or X due to mental status. NECK: Trachea midline. Thyroid symmetrical, mobile, smooth, no palpable nodule. Unable to assess trapezius and sternocleidomastoid motor strength (CN XI). LYMPH NODES: Cervical lymph nodes – Non-palpable and nontender bilaterally. Axillary lymph nodes – Non-palpable and non-tender bilaterally. Inguinal lymph nodes non-palpable and non-tender bilaterally. RESP: Inspection – A/P chest wall jaundiced. Chest rises symmetrically with respiration, symmetrically thoracic expansion. AP diameter 1:2. Rate, rhythm, depth and effort of respiration regular. No accessory muscle use, retractions, nasal flaring or pursed lip breathing. Nontender, resonance across all posterior lung fields. Breath sounds clear to all lobes anteriorly posteriorly and laterally. No adventitious sounds appreciated. CV: No visible impulses; anterior thorax jaundiced. No JVD noted. No cyanosis, pallor or clubbing. No varicose veins. Abdominal ascites. No heaves, lifts or thrills. Apical impulse lies in 5 th intercostal space, midclavicular line. Carotid, dorsalis pedis and posterior tibialis pedis pulses 2+ and symmetrical bilaterally. Heart rate, rhythm regular. S1 and S2 auscultated in aortic, pulmonic, Erb’s point, tricuspid and mitral areas. No S3, S4 or murmurs appreciated. Carotid arties, aorta, renal, iliac and femoral arteries free of bruits. GI: Distended, round. Jaundiced. No lesions, masses or visible pulsations. No visible hernia. Bowel sounds normoactive in all 4 quadrants. Positive fluid wave. Abdomen dull sounds. No tenderness to light or deep palpation. No masses. Liver enlarged. Spleen and kidneys non-palpable. MSK: All joints symmetrical in appearance. Bilateral upper and lower extremities symmetrical, no lesions. Unable to assess ROM or strength of joints due to patient’s mental status. NEURO: All CN per previous documentation. Smell not tested (CN I). Unable to assess dull and sharp sensation. DTRs 2+ and equal bilaterally. Unable to assess gait, point-to-point movements, vibration or position sense due to mental status. PSYCH: Somnolent, does not offer much conversation. Speech is clear, though slow when patient responds. She is oriented to person, place and year. LABWORK: CBC: WBC 18.2 , RBC 3.26, H/H 11.6/34.5, plt 246 , Neutrophils % 78.1 PT 22.1, INR 1.7 CMP: Glucose 88 , BUN 23, Cr 2.0, Na 123 , K+ 4.7, Ca 8.1, Mag 2.0 Total Bili 18.2, AST 99, ALT 33, alkaline phosphatase 195, ammonia 54 UA: Color: orange; Clarity: hazy; Glucose: negative; Bili: Large; Ketones: Trace; specific gravity 1.025; Blood: Trace-lysed; pH 5.0; protein: 30; urobilinogen: 2.0, nitrite: positive; leukocytes: small; Bacteria: 3+ Tox Screen: Positive for methamphetamines, benzodiazepines DIAGNOSTICS: -CXR: Taken upon admission noting bibasilar atelectasis -Urine culture: Positive for E. coli. Pan-sensitive. -CT: Previously done during an admission 3 weeks ago; results not available for my review. -US guided paracentesis: Upon admission, 6700 cc serous fluid withdrawn

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Assessment & Plan: 1. Cirrhosis of liver (K74.60) Cirrhosis of the liver is characterized by late stage progression of hepatic fibrosis, and is typically irreversible when it reaches advanced stages. Generally, the goal of cirrhosis management includes slowing progression of disease, prevention and management of complications and determining the appropriateness or timing for liver transplant consideration. In patients with alcoholic cirrhosis, cessation of drinking has been shown to drastically improve survival rate (Goldberg & Chopra, 2018). TW has been diagnosed with cirrhosis after review of clinical presentation, patient history, imaging studies and lab work review. Major complications of cirrhosis include ascites and hepatic encephalopathy, which are the result of portal hypertension. Onset of these symptoms is considered a decompensation of the disease. Risk factors for decompensation in in cirrhosis may include ETOH intake, infection, blood loss or dehydration. Ascites is the most common complication seen in cirrhosis patients. Treatment involves use of diuretics and sodium restriction for fluid management, as well as paracentesis as needed. Hepatic encephalopathy is characterized by change in neurological status that is in some cases reversible. In addition, patients with cirrhosis may develop hepato-renal syndrome, or onset of renal failure due to reduced renal perfusion as a result of prolonged portal hypertension. Once a patient has become decompensated, it is recommended they be considered for liver transplantation (Goldberg & Chopra, 2018). TW presented with severe jaundice, ascites that was drained via paracentesis and hepatic encephalopathy. The prognosis for these patients is variable, however, once decompensation such as hepatic encephalopathy develops, mortality rates become high. Transplant should be considered, and for patients who are not transplant candidates, hospice care should be considered with an average predicted survival rate of <6 months. The MELD score is a tool used to predict mortality in cirrhosis patients. TW’s MELD score is 31, translating to a 66% mortality rate within the next 3 months (Goldberg & Chopra, 2018). TW is oriented to person, place and time. She is not a candidate for liver transplant due to her ongoing ETOH, tobacco and illicit drug abuse. She voiced her desire to go home and be comfortable. Hospice care was consulted and the patient and family decided together that she would be discharged home with home hospice care as soon as arrangements were made for care at home. 2. Hepatic encephalopathy (K72.91) Patients with hepatic encephalopathy exhibit cognitive impairment as a result of increasing blood ammonia levels. It is graded from I to IV. Based on TW’s symptoms, she is classified as grade III with marked confusion, difficulty with speech and somnolence. In order to lower ammonia levels, recommended treatment includes use of lactulose, lactitol or rifaximin. First line therapy is lactulose 20 to 30 grams given BID to QID. The dose is to be titrated until the patient achieves 2-3 stools per day. If patients remain unchanged after 48 hours of lactulose therapy, treatment with rifaximin is indicated at 400 mg TID. A protein intake of 1.2 to 1.5 g/kg/day is also recommended once the patient is improved to the point of being able to consume food (Ferenci, 2018). Based on her current medications, TW has been on appropriate treatment for management of her encephalopathy. She is not consuming many calories, but declines to participate further in care and has opted for hospice measures only. 3. Urinary tract infection (N39.0) Urinary tract infections (UTIs) include cystitis (confined to the bladder) and pyelonephritis. E. coli is the most common causative organism. Symptoms of acute simple cystitis include dysuria, frequency, urgency, and/or suprapubic pain (Hooton & Gupta, 2018). TW did not report any of these symptoms, however, she was also unable to provide much of her history upon admission due to her mental status. A UA was obtained, which aids in diagnosis of UTI. UTI is indicated when results are positive for leukocytes and nitrite (Hooton & Gupta, 2018). TW’s UA was positive for nitrite, leukocytes and 3+ bacteria. Blood work may also be obtained to assist in ruling out complicated UTI. TW’s WBC is elevated. Urine culture and susceptibility can be helpful in determining the correct course of antibiotic therapy. First line therapy for acute simple UTIs includes empiric therapy with broad spectrum antibiotics until culture results are obtained (Hooton & Gupta, 2018). The organism grown was E. coli. She was initially started on IV Rocephin, which is a broad spectrum antibiotic. Her culture and sensitivity report revealed that the organism is susceptible to Rocephin and therefore the patient should be continued on this medication for the full course of treatment. 4. Depression (F33.9) It is recommended that initial treatment for patients with a known history of depression is the use of a selective serotonin reuptake inhibitor (SSRI) (Simon, 2017). Reduction in serotonin reuptake increases the time that serotonin is available within the brain, and therefore improves mood and behavior. The full therapeutic effect of SSRIs is not reached until 3-8 weeks after the beginning of treatment (Hirsh & Birnbaum, 2018). TW’s family reports she has a known history of depression that she previously took Zoloft, an SRRI. However, upon medication reconciliation with her pharmacy, the patient has not picked up her medication in some time. She declined suicidal ideation upon interviews. Based on the patient’s current prognosis, initiation of medical therapy with an SSRI may not be beneficial, as therapeutic effects take time. She was initiated on Zoloft at 50 mg daily this admission, which is consistent with recommended guidelines. 5. Alcohol dependence (F10.29) In the hospital setting, patients who have abruptly discontinued alcohol consumption due to acute illness are subject to symptoms of withdrawal. These may include insomnia, anxiety, GI upset, agitation, headache and diaphoresis and occur within 6 hours of drinking cessation. In more severe cases, patients withdrawing from ETOH may develop tonic-clonic seizures or delirium tremens (DT). DT typically occurs 48-96 hours after the last drink. Management involves supplementation and adequate management of electrolytes including thiamine, folate, glucose, phosphate, potassium and magnesium. TW is on electrolyte replacement protocol as recommended. Benzodiazepines are the recommended treatment for agitation and to prevent worsening of withdrawal symptoms. The first-line

recommended drugs are diazepam (Valium) 5 to 10 mg every 5to 10 minutes PRN, or chlordiazepoxide (Librium) 25 to 100 mg hourly PRN. In patients with alcoholic cirrhosis, lorazepam (Ativan) 2 to 4 mg IV every 15- 20 minutes may be considered due to shorter half- life of the drug and reduces over sedation (Hoffman & Weinhouse, 2018). While TW’s Librium at 5 mg TID is consistent with recommended guidelines for DT prevention, I would have chosen differently for this patient when prescribing medication. Based on knowledge that TW has alcoholic cirrhosis and Ativan has a shorter half-life, I would have ordered Ativan 2 mg IV every 20 minutes PRN for DT prevention. Follow-up: Follow up after discharge with hospice RN to ensure patient was supplied with all necessary medical supplies and pain control medications once arriving home with home hospice care. No further medical follow up is necessary in this patient’s case, as she will be comfort care only. Patient Education: The patient expressed no desire in the face of a poor prognosis to stop drinking, smoking or drug use. However, her son and boyfriend were present in the room, and both were educated on the importance of smoking, drinking and drug cessation in order to preserve their own health. They were counseled and encouraged to seek assistance with their primary care providers for help if needed. The patient and her family were also educated on the process of hospice care, and what expectations they should have. Referrals: The patient was referred to home hospice after expressing her desire to go home and not remain in the hospital any longer. Her family was in agreement and a representative RN from the home hospice services was consulted and arranged discharge planning for the patient. E/M codes: 99232 – LEVEL 2 HOSPITAL SUBSEQUENT CARE FOLLOW UP VISIT CPT codes: 36415 – VENIPUNCTURE 85025 – COMPLETE CBC & AUTOMATED DIFFERENTIAL 80053 – COMPREHENSIVE METABOLIC PANEL 80076 – HEPATIC FUNCTION PANEL 82140 – AMMONIA, PLASMA LEVEL 81000 – URINALYSIS 87088 – URINE CULTURE 87181 – URINE CULTURE ANTIBIOTIC SENSITIVITY References: Ferenci, P. (2018). Hepatic encephalopathy in adults: Treatment. UpToDate. Retrieved from https://www.uptodate.com/contents/hepatic-encephalopathy-in-adults-treatment?search=hepatic %20encephalopathy&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1 Goldberg, E., & Chopra, S. (2018). Cirrhosis in adults: Overview of complications, general management, and prognosis. UpToDate. Retrieved from https://www.uptodate.com/contents/cirrhosis-in-adults-overview-of-complications-general-management-and- prognosis?search=cirrhosis&source=search_result&selectedTitle=2~150&usage_type=default&display_rank=2 Hirsh, M., & Birnbaum, R. J. (2018). Selective serotonin reuptake inhibitors: Pharmacology, administration, and side effects. UpToDate. Retrieved from https://www.uptodate.com/contents/selective-serotonin-reuptake-inhibitors-pharmacology-administration-and- side-effects?search=SSRIs&source=search_result&selectedTitle=2~150&usage_type=default&display_rank=2 Hoffman, R. S., & Weinhouse, G. L. (2018). Management of moderate and severe alcohol withdrawal syndromes. UpToDate. Retrieved from https://www.uptodate.com/contents/management-of-moderate-and-severe-alcohol-withdrawal-syndromes? search=alcohol%20withdrawal%20protocol&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1 Hooton, T. M., & Gupta, K. (2018). Acute simple cystitis in women. UpToDate. Retrieved from https://www.uptodate.com/contents/acute-simple-cystitis-in-women?search=urinary%20tract %20infection&source=search_result&selectedTitle=3~150&usage_type=default&display_rank=3 Simon, G. (2017). Unipolar major depression in adults: Choosing initial treatment. UpToDate. Retrieved from https://www.uptodate.com/contents/unipolar-major-depression-in-adults-choosing-initial-treatment? search=depression&source=search_result&selectedTitle=2~150&usage_type=default&display_rank=2#H432086717

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