example write up 2

SUMMARY OF H&P

Mr P. is a 73 year old gentleman who had just transferred back from the inpatient hospital to the nursing home at Via Christi Catholic Care Center. He has a history of a stroke with subsequent Broca’s aphasia, BPH, a history of heart failure and he was admitted at St Francis for AKI, hyperkalemia requiring emergent dialysis x 2, as well as cellulitis of the lower extremities. The precipitating cause for his renal failure was thought to be secondary to several different NSAIDs, Spironolactone, and concomitant use of Lasix and Lisinopril. The patient had returned to the care center for about 1 week when he started having more complaints of urinary incontinence. He said he was having increasing nocturia, felt that his bladder was full but by the time he made it to the bathroom he had already lost “several tablespoons” worth of urine. Moreover, per nursing, the patient was refusing to take most of his medications for fear that he would have to go to the hospital again. Some of these meds he was refusing included his Clindamycin for his cellulitis. The patient was not delirious, alert, oriented, and had good memory recall.

DIMENSIONS OF CARE

1. Structure and Process of Care

a. The patient had just been discharged from St. Francis Hospital about one week prior. He returned to his status in the nursing home and was thought to have returned to stable condition. The medications for which he was to continue and stop were clearly documented in the discharge note, papers, and orders.

2. Physical Aspects of Care

a. Urinary Incontinence, Overflow – the patient had been complaining of some itchiness of his extremities and was given Benadryl for the previous week. It was thought that the anticholinergic properties of the Benadryl in addition to the patient’s baseline BPH was exacerbating his symptoms

b. Broca’s Aphasia 2/2 to hx of Stroke – pt had difficulty finding the words to convey his meaning and frequently had to pause to communicate

c. Cellulitis – was supposed to be taking Clindamycin as prescribed from the hospital, but was not doing when I first visited him

3. Psych Aspects of Care

a. The largest psych component had to deal with the patient’s frustration and depressed mood regarding his aphasia. He had a history of anger problems, usually exacerbated by not being able to get the words out he wanted to, and would become violent. The patient had a history of being hospitalized in an inpatient psychiatric hospital in Newton for depression/anger management.

b. In addition, the patient was anxious about returning to the hospital and was not taking his medications. He understood that the most likely precipitating factor of his AKI was medication induced. Given that he blindly takes medications that are given to him by nursing, he was afraid that the same thing was going to happen again.

4. Social Aspects of Care

a. I was able to talk to the patient about his married life, and later to the nurses about it. In a rather unique sequence of events, the patient had been previously married for 40 years, got divorced, and then remarried years later after his wife’s 2nd husband passed away from stage IV lung cancer. His prior history of anger was typically directed at her. Per nursing, the patient was always kind, pleasant, warm to them, but when the patient’s wife came to the nursing home to visit, it was noticeable that his wife would push him and urge him to hurry up and blurt out what he was trying to say—something that was clearly very frustrating to him given his aphasia. I did not personally see the patient’s interaction with his wife, but it was clear that there were some suboptimal dynamics between the patient and his wife.

GERIATRIC COMPETENCIES

(4) – “Appropriately administer and interpret the results of at least one validated screening tool for each of the following: delirium, dementia, depression, and substance abuse.”

· The patient already had a diagnosis of depression, but I did do a PHQ-9 Screening Test which is usually a good screening test for depression. The patient received a score of 7 which corresponds to mild depression. I reviewed his medications and noted that he was already receiving an SSRI. I did not have a prior PHQ-9 test to compare, but I was hoping that his depressive symptoms had improved over time. It should be noted that his symptoms were mostly related to his frustration of his aphasia and inability to convey his thoughts clearly and quickly.

(7) – “In patients with dementia and/or depression, initiate treatment and/or refer as appropriate.”

· As mentioned above, that patient was already on an SSRI for his depression, and it was deemed that this was adequate.

(8) – “Identify and assess barriers to communication such as hearing and/or sight impairments, speech difficulties, aphasia, limited health literacy, and cognitive disorders. When present, demonstrate ability to use adaptive equipment and alternative methods to communicate.”

· The patient’s aphasia was clearly the biggest barrier to his communication. His cognition and hearing was fair. His sight was fair enough with glasses. His cognition was good. I was able to bring a nurse in who knew him well to help me better understand what he was asking/telling me. For the most part, I could ultimately understand what he was saying, but it just took some time. I gave him my clipboard and pen and paper in case he needed it to communicate as well. He used it a few times but usually still tried to convey his meanings verbally. I think the best thing was simply sitting with him on his bed and patiently listening until he was all done, giving gentle physical and verbal queues when I understood what he was saying. I tried not to rush him.

· In addition, I sat with the patient and discussed with him his anxiety about taking his medications. I listened to why he has been refusing his medications, and how he thought taking them would put him right back into the hospital with renal failure. I spent some time reassuring him of the communication we had with the doctors who discharged him, saying that we have orders from them of exactly which drugs to stop. I discussed with him why some of his medications caused his renal failure, and I reassured him that we know exactly which ones those are and that those have already been taken off his medication list. I then reassured him that the other medications have no effects on the kidney and that they are safe to continue, and that those are the only medications the nurses are bringing to him. Fortunately, by the following day, the patient was taking his medications as instructed, including his Clindamycin.

(11, 14) – “Consider adverse reactions to medication in the differential diagnosis of new symptoms or geriatric syndromes.”

· The patient’s initial complaint had to deal with his urinary incontinence, which was actually multifactorial. The patient had started taking Benadryl about one week prior. Benadryl has anticholinergic properties which can block the detrusor muscle from contracting. In addition, the patient had a history of BPH which exacerbates overflow incontinence. Thirdly, due to the patient’s cellulitis and heart failure, it was still felt he needed to continue his Lasix, but simply at a lower dose.

· To amend this situation, we discontinued his Benadryl to allow the detrusor muscle to better contract. We also started low dose Tamsulosin 0.4mg PO qd for its prostate selective alpha blocking properties. Regarding the Lasix, to reduce the patient’s nocturia, we frontloaded the patient’s Lasix to be early in the morning and at noon, so that he would already be “maximally diuresed” by the time he went to bed.

(22) – “In transfers between the hospital and skilled nursing or extended care facilities, ensure that: for transfers to the hospital: the caretaking team has correct information on the acute events necessitating transfer, goals of transfer, medical history, medications, allergies, baseline cognitive and functional status, advance care plan and responsible PCP; and for transfers from the hospital: a written summary of hospital course be completed and transmitted to the patient and/or family caregivers as well as the receiving health care providers that accurately and concisely communicates evaluation and management, clinical status, discharge medications, current cognitive and functional status, advance directives, plan of care, scheduled or needed follow-up, and hospital physician contact information.”

· As discussed above, I took note of the importance of interfacility transfers and discharge notes. While I did not do the discharge orders, I read them to make sure of which medications were to be stopped and which were to be continued. I had a clearly documented hospital course and management summary of the prior hospital stay, all of which was vital for the continued care of the patient in the nursing home, especially in reference to his medications.

LITERATURE

In general, urinary incontinence affects 15-30% of elderly individuals in the community and 50% of those living in nursing homes. Physiologic properties can predispose the elderly to urinary incontinence. Overall bladder capacity is reduced, post-void residual urine volumes are elevated, and patients tend to produce higher volumes of less dilute urine 2/2 to reduced renal concentrating abilities. Slower reactions times and limited mobility make it difficult for patients to reach the bathroom on time. In addition, BPH worsens outlet obstruction and become more prevalent in men (1). A common problem seen in the elderly is detrusor hyperactivity and impaired contractility—it is common in frail elderly and can be difficult to treat (2). One of the first things to address is behavorial therapy. One study showed a 26% reduction in incontinence and 38% improvement in incontinence by prompting frequent voids (3). Among medical approaches, it is suggested that elderly men with BPH can try alpha-blocker therapy. Tamsulosin is one such agent that has a much lower risk of hypotension and dizziness due to it’s prostate-selective alpha blocking properties and is the best recommended among alpha blockers (4).

The patient most likely has overflow incontinence, primarily caused by his BPH, but also probably worsened by starting Benadryl. Benadryl has anticholinergic properties which prevent the bladder from contracting as well. By stopping the Benadryl we were hoping to allow the detrusor muscle to better contract against an enlarged prostate. Then, we also started a low dose Tamsulosin to help relax the smooth muscle of the prostate around the urethra. It was thought the patient had previously been on Tamsulosin at one time, but it was indeed restarted.

1. Hunskaar S, Arnold EP, Burgio K, et al. Epidemiology and natural history of urinary incontinence. Int Urogynecol J Pelvic Floor Dysfunc 2000; 11:301-319.

 

2. Griffiths DJ, McCracken PN, Harrison GM, et al. Urge incontinence and impaired detrusor contractility in the elderly. Neurourol Urodyn 2002; 21:126-131.

 

3. Hu TW, Igou JF, Kaltreider DL, et al. A clinical trial of a behavioral therapy to reduce urinary incontinence in nursing homes. Outcome and implications. JAMA 1989; 261:2656-2662.

 

4. Klausner, Adam P, Vapnek, Jonathan M. Urinary Incontinence in the Geriatric Population. Mount Sinai Journal of Medicine 2003; 70:54-62.