Mr Yoder’s Hospital Stay

Name: Sherman “Red” Yoder
Gender: M     Age: 80       Race: Caucasian   Weight:  109 kg  240 pounds       Height:  183cm      72 inches
Religion: Protestant      Major Support: Jon (son)    Phone: 869-555-3452
Allergies:    No known allergies
Immunizations:   Influenza last fall;  tetanus – 4 years ago
Past Medical History:  Diabetes Type 2 diagnosed July of this year.

History of Present illness:   Complaints of fatigue.  This patient had also developed an ulcer on his big toe 3 weeks ago. Has been soaking his foot to heal the wound; recently revealed the wound to his family.
Chief Complaint:  Patient stated “I have pain in my big toe and my right foot”.
Social History:  Widower; his son Jon lives nearby
Primary Medical Diagnosis:  Diabetic foot ulcer, Type II diabetes, Sepsis
Current Medications:  Metformin 1000mg PO BID; Insulin Lantus 10 Units SQ QD x 1 month; Benadryl 25-50 mg at HS prn insomnia; APAP 1000mg prn.
Surgeries/Procedures & Dates:  L4-5 laminectomy – 25 years ago; transurethral resection of the prostate – 6 years ago

Hygiene and sleep patterns:  Showers 2 to 3 times a week, oral care performed daily, sleeps approximately 5 hours per night with naps while watching tv during the day.
Alcohol/smoking/drug history:  Client denies use of alcohol or illicit drugs.  History of chewing tobacco for approximately 30 years.  Client quit chewing tobacco 15 years ago. No history of smoking.
Educational data:  Client denies the need for special cultural, dietary or religious considerations.  Client states he learns best by doing.  Risk for readiness to learn.
Functional Screen:  Client currently lives alone and states “I’m having more trouble taking care of my house and myself each day that goes by”.  Able to shower occasionally and dress himself with effort. 
Fall Risk:  High fall risk.  Client unsteady on his feet and holds onto furniture to get around.  No ambulatory aides are currently used.
Nutrition screen:  Client states “I eat frozen meals as they are easy to prepare being alone.  I don’t worry about what it is and am not worried about my diabetes”.

Nursing assessment day 1 - medical / surgical unit

Wound Consult: Medial right great 1 cm x 1.5 cm surface area 1.5 cm2 calloused, wound bed 50% yellow necrosis, pale pink viable tissue, bleeds with palpation, minimum exudate. Erythema noted around the wound. Perineal and anal areas reddened.

Patient direct admit by doctor’s recommendation to obtain wound nurse evaluation of right great toe wound. Patient cheerful, talking and infusing 0.45 sodium chloride in right AC 20 gauge.

Nurse signatures
Initial        Nurse Signature     
NS            Nancy Smith, RN

 

Patient complaining of SOB.  Physician contacted.  Vitals and SOB reported. Advised foot wound has no visible changes. Physician request to transfer patient to ICU state.

Nurse signatures
Initial      Nurse Signature
NS          Nancy Smith, RN

 

Patient stable with no complaints of SOB. Wound dressing changed.  Physician order to transfer patient to Medical-Surgical Floor.

Nurse signatures
Initial     Nurse Signature
DJ          Diane Jones, RN

 

Wound Consult: Medial right great 1 cm x 1.5 cm surface area 1.5 cm2 calloused, wound bed 50% yellow necrosis, pale pink viable tissue, bleeds with palpation, minimum exudate. Erythema noted around the wound. Perineal and anal areas reddened.

Patient direct admit by doctor’s recommendation to obtain wound nurse evaluation of right great toe wound. Patient cheerful, talking and  infusing 0.45 sodium chloride in right AC 20 gauge.
Nurse signatures
Initial      Nurse Signature
NS          Nancy Smith, RN

 

Patient Name:  Yoder, Sherman
Reason For This Admission:  Open wound R great toe, Sepsis,  IDDM
PMH:  L4-L5 Laminectomy aprox  1990, Prostate surgery/TURP , aprox 2008
 

S:    Initially,  “Oh…you’re a sweet gal, but I think you maybe have the wrong room…I am obviously a bit too old to be finding a new job.”   OTR/L clarified the role of occupational therapy and then patient agreed to participate.   “I guess I’m here because everyone is worried about my toe….I didn’t realize it was such a big deal…I figured it would probably heal on its own if I just kept soaking it…..what I know now after talking to the nurses is that it is way more serious than I thought, and I guess most people would have had more pain that would have told them that a few weeks ago.  They are saying that between my diabetes and my laminectomy, I probably don’t feel things normally and so it got really bad before I really knew it.”

O:  OTR/L began eval after reviewing chart.  According to nursing notes pt is here to be treated due to R great toe open wound and sepsis.  He was DX with IDDM aprox 6 months ago and is on insulin.  He is described as A & O, conversant, able to drive, and living alone with some help from son, Jon and daughter in law Judy who live near his farm outside Edina Mo.  OT eval was requested by Judy, who is questioning his ability to live by himself.

Perception  Pt wears bifocals.  He had no difficulty following conversation and expressed himself with ease.  No word finding issues were observed.  Pt does not use hearing aids. 

Cognitive:  Pt scored  24 out of 30, suggestive of mild cognitive impairment, on the MOCA with 2 points lost for concrete responses regarding the abstraction subtest.  Pt has a high school education.

Sensation:  UE sensation is intact.  Pt  does complain that he has to fumble for things like coins and keys.

Strength/ROM:  UEs WFL and pt has no complaints.

ADL:   Nursing notes indicate he scores “6” on the KATZ.    OTR performed the  Kohlman Evaluation of Living Skills administered through interview and direct observation of actual abilities.    Pt scored as Independent in health, money management, transportation, telephone and leisure and needs assistance in areas of daily activities in self care, safety and health.     Pt is I with feeding.  He denies problems with chewing, choking or swallowing, but states that his tongue has felt different lately.   Pt is I with toileting but c/o prbs with reaching to wipe and so OTR instructed him in some alternate techniques to support and elongate the spine and pt agrees he will practice and let therapist know his success.  Pt c/o intermittent sleep problems and attributes them to prbs getting physically comfortable due to pain in his feet and legs at times that he rates as a “5”. 

Mobility: Pt is using a FWW in an attempt to keep weight off the toe and relieve pain, but admits he actually is finding it helpful.   As determined by PT eval, if he will be continuing with FWW, he may benefit from obtaining a walker tray or basket in order to transport items.    He arose easily from the bed, chair and toilet.

Psychosocial/Family: During  OT eval, pts son John visited briefly on his way to work.  OTR advised him that Mr Yoder will likely need some adaptive equipment in order to improve his safety with ADL.  John stated he does not know when he can get to that issue and expressed frustration with his dad’s needs for assist….”Holy Cow!….we already stop by there about every other day as it is!  Our own lives are turning to CRAP, and it looks like my son is going to get kicked out of college or at the very least lose his scholarship….and now THIS!  I don’t know how much of this SHIT I can take…I’m about done.  We’re going to have to talk about this more later….here Dad….I brought you the paper….I gotta go…..sorry.”    After John left, the pt apologized profusely for his behavior and admitted it has gotten worse and worse lately to the point that Mr Yoder avoids bringing up issues that he knows will create more work for John or Judy.  Mr Yoder denies that there is anything more than shouting and specifically denies that John  has ever hurt him.   Pt accepted the offer of leaving an adaptive equipment catalog with the specific items that might help him circled and he said he planned to talk to John about it later, “after he cools off”. 

A:  The following issues will be addressed by OT:

1. Pt requires SBA during bathing due to safety risk and admits to falling 2x in recent months when he arose quickly to answer the door or phone.   Pt sates he has no adaptive equipment in the home and has been a bit scared about bathing on his own and so has recently resorted to just sponge baths at the sink.  
2. Pt requires MIN A for LE dressing due to decreased ROM of his lower back with residual decreased sensation of R LE, RT to laminectomy and or neuropathy.   Pt has no adaptive equipment and admits he does not change his socks daily because he is unable to get them on. 
3. Impaired communication/family support system.

Goals For OT:

1. Pt will demonstrate safe Shower with adaptive equipment within 1 wk.  
2. Pt will demonstrate I LE dressing using adaptive equipment and techniques with 1 wk
3. Determine specific unmet needs of client and explore community resources to reduce caregiver burden

Strengths:

1. Cognitively intact
2. Involved family

OT Planned Interventions:  OT 1x day x 7-10 days

1. OTR/L will further assess for potential to benefit from use of tub transfer bench, long handle scrub sponge and bath mat.  Will provide safety training.  
2. OTR/L  will provide instruction in use of dressing stick, sock donner and long handle shoe horn for LE dressing.  Will encourage regular skin inspection using long handle mirror.  
3. Request MSW eval to explore community resources that may reduce caregiver burden and to explore ways to improve communication/rapport between pt and son.  

DC Plan:  Dc in 1-2 weeks or when goals met.  Pt will benefit from home health OT to insure carry over to his own home situation, evaluate his safety in his own natural environment,   and to help family adjust to his new status.  Evaluation of meal prep would be most effective in his own home.  Pt might benefit from meals on wheels, the friendly visitor program, or other ways to expand his social circle and support beyond his own family. 

Olivia Opres, OTR/L

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Health Educator/Health Education Specialist NOTES and ASSESSMENTS

Health Educators/Health Education Specialists: Job Description

The U.S. Department of Labor Bureau of Labor Statistics (BLS) defines health educators (SOC 21-1091.00) as those who promote, maintain, and improve individual and community health by assisting individuals and communities to adopt healthy behaviors, collect and analyze data to identify community needs prior to planning, implementing, monitoring, and evaluating programs designed to encourage healthy lifestyles, policies and environments. They may also serve as a resource to assist individuals, other professionals, or the community, and may administer fiscal resources for health education programs. http://www.bls.gov/soc/soc_f1j1.htm

Health Education Specialist Responsibilities and Competencies
Area I: Assess Needs, Assets and Capacity for Health Education
Area II: Plan Health Education
Area III: Implement Health Education
Area IV: Conduct Evaluation and Research Related to Health Education
Area V: Administer and Manage Health Education
Area VI: Serve as a Health Education Resource Person
Area VII: Communicate and Advocate for Health and Health Education

Brief Video about Certified Health Education Specialists/Roles and Responsibilities: http://www.sophe.org/healthedspecialist.cfm

Brief Videos: What is Public Health/This is Public Health:

http://www.whatispublichealth.org/what/

http://www.thisispublichealth.org/video_lowres.html

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A.     DIABETES MANAGEMENT – NUTRITION/HEALTH EDUCATION

Nutrition Assessment items
For diabetes knowledge (to inform education needs): Michigan Diabetes Research and Training Center Brief Diabetes Knowledge Test – pdf.
Screens for current diet - They are free online.  The one specific to carbohydrate intake must be purchased, but these are still good for providing a snapshot of the patient’s diet.
Fruit/vegetable/fiber intake  - http://www.nutritionquest.com/wellness/free-assessment-tools-for-individuals/fruit-vegetable-fiber-screener/
Fat intake - http://www.nutritionquest.com/wellness/free-assessment-tools-for-individuals/fat-intake-screener/

Nutrition Education item
Tips for meal planning:
Six Easy Steps to Create Your Plate
It’s simple and effective for both managing diabetes and losing weight. Creating your plate lets you still choose the foods you want, but changes the portion sizes so you are getting larger portions of non-starchy vegetables and a smaller portion of starchy foods. When you are ready, you can try new foods within each food category.
Try these six simple steps to get started:
1. Using your dinner plate, put a line down the middle of the plate. Then on one side, cut it again so you will have three sections on your plate.
2. Fill the largest section with non-starchy vegetables such as:

• spinach, carrots, lettuce, greens, cabbage, bok choy
• green beans, broccoli, cauliflower, tomatoes,
• vegetable juice, salsa, onion, cucumber, beets, okra,
• mushrooms, peppers, turnips

3. Now in one of the small sections, put grains and starchy foods such as:

• whole grain breads, such as whole wheat or rye
• whole grain, high-fiber cereal
• cooked cereal such as oatmeal, grits, hominy or cream of wheat
• rice, pasta, dal, tortillas
• cooked beans and peas, such as pinto beans or black-eyed peas
• potatoes, green peas, corn, lima beans, sweet potatoes, winter squash
• low-fat crackers, snack chips, pretzels and light popcorn

4. And then in the other small section, put your protein such as:

• chicken or turkey without the skin
• fish such as tuna, salmon, cod or catfish
• other seafood such as shrimp, clams, oysters, crab or mussels
• lean cuts of beef and pork such as sirloin or pork loin
• tofu, eggs, low-fat cheese

5. Add a serving of fruit, a serving of dairy, or both as your meal plan allows.
6. To complete your meal, add a low-calorie drink like water, unsweetened tea, or coffee.

Source: American Diabetes Association (2014) Create your plate. Retrieved from http://www.diabetes.org/food-and-fitness/food/planning-meals/create-your…

Nutrition Education Caregiver item
8 Tips for Caregivers
From Diabetes Forecast
By Lindsey Wahowiak
March 2014
A diabetes diagnosis can be overwhelming. As caregivers, we want to support our loved ones and help them enjoy the healthiest lives possible. But what is the best way to do that? We talked to experts—both health care providers and people who have been there—to learn what is helpful and what to avoid.

Start Your Education Now
Any diagnosis presents a learning curve. Your first and best step in becoming an ally for your loved one is to arm yourself with education, says Shantanu Nundy, MD, of Mary’s Center, a Washington, D.C., health care and social services center for low-income families.
Some people believe that diabetes is “not a big deal” or, alternately, that it’s a death sentence, so it’s important to know the facts. “As physicians, we try to debunk [misconceptions], but information coming from a trusted family member or friend is really powerful,” Nundy says. “[Diabetes is] something you can live a long, healthy life with, by managing it.”
You can ask your loved one’s health care provider about where to learn more, including books, online communities, support groups, and sites such as the American Diabetes Association’s diabetes.org.
The learning curve can be steep, says Stacey Simms, whose 9-year-old son, Benny, was diagnosed with type 1 seven years ago, but she says it has been manageable for her and him. “My advice is to take a deep breath and realize that the beginning is the worst,” Simms says. “Now it’s just our routine, and it will become yours as well, eventually.”

Take Some Time
You can learn things and make changes bit by bit, to avoid overhauling your lives based on a loved one’s diabetes.
Jessie Gruman, PhD, should know. She’s a psychologist and five-time cancer survivor who wrote a book on coping with a new diagnosis: AfterShock: What to Do When the Doctor Gives You—or Someone You Love—a Devastating Diagnosis. She suggests giving yourself and your loved one time to digest the information. “People are shocked, and they feel like their life has changed in these earth-shattering ways,” she says. “As we learn more, as time goes by, as we adjust, as we make decisions, the way we feel changes a lot.”
So don’t rush your loved one (or yourself) from mourning to acceptance. Instead of saying, “You’re not going to feel this way tomorrow,” it may be more helpful to say, “This is really scary. What are you most worried about?

Encourage Self-Care, but Don’t Be a Pest
There’s a fine line between checking in on someone’s well-being and what Gerald Strauss, PhD, a psychologist with the Veterans Affairs (VA) health care system, calls “miscarried helping”—also known as nagging.
“Though people really do want to help their loved ones with diabetes, this backfires and just sends people running in the opposite direction,” he says. Don’t pester: Explain what you would appreciate your loved one doing. Strauss suggests role-playing these requests with health care providers or a diabetes care team to make sure your approach will be well-received.
Of course, with children, you will have to supervise, so weigh how much they might be able to handle on their own, advises Anne Doyle, a member of the Diabetes Forecast Reader Panel. Her daughters both have type 1 diabetes. “Give them one task at a time, and give them time to be successful at it,” she suggests. “Also be ready to take some responsibilities back from your child if you see them struggling.”
Preteen and teenage children often need parental supervision to stay consistent with care.

Make Changes Together
Your loved one’s diagnosis probably means making some lifestyle changes. Going through that alone might feel isolating, so why not make the changes together as a team or household? Start exercising together or look for diabetes-friendly recipes together—then cook and eat them together.
“A lot of the things that improve the care for someone with diabetes are actually good for everybody,” Nundy says. “It’s always better than going it alone.” Nundy knows this firsthand: He’s helped his mom care for her type 2 diabetes.

Set Small Goals
Taking a step-by-step approach is the easiest way to make permanent lifestyle changes, says Elizabeth Koustis, RD, LD, of the VA. Doing small things, such as taking a walk after dinner, can improve blood glucose and overall diabetes management, and allow you to look at the results and reevaluate as needed. “I think that’s very motivating for the patient, and they can continue to move forward,” Koustis says.
Offer help only if you really mean it. Saying “let me do anything I can to help you” is so broad, most people won’t take you up on it. So be specific about what you’re able to help with, and offer only if you really can help, says Gruman. “There’s nothing harder than to ask for help and then have it refused,” she says. So can you give your loved one a ride to the doctor? Then offer that—it’ll be appreciated.

Work With the Diabetes Care Team
Attend doctor’s appointments and diabetes education classes together if your loved one agrees. Nundy suggests listening to what both health care providers and the patient are saying, chiming in with what you know, and asking questions to help your loved one get the best care possible. That includes making sure the health care team is complete, including, say, a dietitian or a mental health counselor, if needed.
“Often doctors don’t know that patients are having trouble with their medications or [aren’t] able to follow a diet plan, and patients are often reluctant to share this information with the doctor or simply are too overwhelmed with their care,” Nundy says. “Caregivers can advocate for their loved ones simply by listening and sharing with the doctor, and then trusting them to make the right decisions that reflect their loved ones’ needs.”

Find Support for Yourself
The best way to be a caregiver is to take care of yourself, too. “Not only does the patient feel stress, but I think it’s important to explain that the caregiver can feel the stress,” says Kathryn Leciejewski, PharmD, BCACP, who works with Strauss and Koustis at the VA. “Acknowledging it can help with coping with it.” If you can find a support group for caregivers, so much the better. Kara Wilson was able to meet other parents of children with diabetes after her son, Isaac, was diagnosed with type 1 diabetes in 2012. “It helps so much to meet others who are going through exactly what you are dealing with,” Wilson says. “We need to hug each other and take comfort in the support we can offer one another.”

B.     DIABETES MANAGEMENT – PATIENT SELF-MANAGEMENT AND HEALTH EDUCATION

Health Educators deliver Community-based Lifestyle Change Programs: The CDC DPP Curriculum is based on the Diabetes Prevention Program (DPP). The DPP was a clinical research study led by the National Institutes of Health and supported by the Centers for Disease Control and Prevention. Studies subsequent to the DPP determined how best to implement the program where people live and work. Read more about the curriculum. http://www.cdc.gov/diabetes/prevention/recognition/curriculum.htm

Diabetes self-management is seen as the cornerstone of care for all individuals with diabetes who want to achieve successful health-related outcomes and is considered most effective when delivered by a multidisciplinary team with a comprehensive plan of care. There is a growing body of literature on both educational and psychosocial interventions, aimed at helping individuals to better manage their diabetes. There is some evidence for the effectiveness of self-management education, including community-based peer support groups and ongoing home telephone support.
            Online support: http://www.diabetesselfmanagement.com/about/
            Community-based peer support: http://moarthritis.typepad.com/northeast_missouri_rac/ - (Living a Healthy Life classes) –
 
LOCAL: http://moarthritis.typepad.com/northeast_missouri_rac/Kirksville%20DSMP%…
            Diabetes Self-Management Toolkit: http://moarthritis.typepad.com/selfmanagement_toolkit/chronic-condition-…

C.     DIABETES SELF-MANAGEMENT AND PHYSICAL ACTIVITY

Assessments:

Physical Activity readiness Questionnaire: http://exerciseismedicine.org/documents/A_EIM_PAR-Q.pdf

Health Education: http://diabetes.niddk.nih.gov/dm/pubs/physical_ez/  ; http://www.diabetes.org/food-and-fitness/fitness/ 

D.     DIABETES SELF-MANAGEMENT: MAKING AN ACTION PLAN WITH YOUR CLIENT

My visit with:  Dr. Thomas          Date:     June 15, 2009                
Things we talked about / Things I need to do:
            http://www.diabetes.org/food-and-fitness/fitness/
            Increase evening insulin dose from 20 to 25 units.   
            Make an appointment with the eye doctor.  Call Main Street Ophthalmology at             555-9837.

Action Plan
One goal I want to achieve that will improve my health: 
Lose 10 pounds with exercise and diet changes
One specific step I can take to achieve this goal:
Increase my exercise with regular walking.
What: Walking
How Much: 30 to 40 minutes
When:  During my weekday lunch breaks; Sunday or Saturday morning in the neighborhood with my wife.
How Often: Four times a week
How sure am I that I can do this?

       1         2         3         4         5         6         7         8         9         10

      Not sure                                                                                                Very sure    

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Health Educator/Health Education Specialist NOTES and ASSESSMENTS

Health Educators/Health Education Specialists: Job Description

The U.S. Department of Labor Bureau of Labor Statistics (BLS) defines health educators (SOC 21-1091.00) as those who promote, maintain, and improve individual and community health by assisting individuals and communities to adopt healthy behaviors, collect and analyze data to identify community needs prior to planning, implementing, monitoring, and evaluating programs designed to encourage healthy lifestyles, policies and environments. They may also serve as a resource to assist individuals, other professionals, or the community, and may administer fiscal resources for health education programs. http://www.bls.gov/soc/soc_f1j1.htm

Health Education Specialist Responsibilities and Competencies
Area I: Assess Needs, Assets and Capacity for Health Education 
Area II: Plan Health Education 
Area III: Implement Health Education 
Area IV: Conduct Evaluation and Research Related to Health Education 
Area V: Administer and Manage Health Education 
Area VI: Serve as a Health Education Resource Person 
Area VII: Communicate and Advocate for Health and Health Education

Brief Video about Certified Health Education Specialists/Roles and Responsibilities: http://www.sophe.org/healthedspecialist.cfm 

Brief Videos: What is Public Health/This is Public Health: 
http://www.whatispublichealth.org/what/ 
http://www.thisispublichealth.org/video_lowres.html

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A.    SMOKELESS TOBACCO AND TOBACCO CESSATION – HEALTH EDUCATION

Mouth lesions - Leukoplakia is a white patch in the mouth that can become cancer. These are sometimes called sores but they are usually painless. Many studies have shown high rates of leukoplakia at the place in the mouth where users place their chew or dip. One study found that nearly 3 out of 4 daily users of moist snuff and chewing tobacco had non-cancerous or pre-cancerous lesions (sores) in the mouth. The longer a person uses oral tobacco, the more likely they are to have leukoplakia. Tobacco can irritate or destroy gum tissue. Many regular smokeless tobacco users have receding gums, gum disease, tooth decay (from the high sugar content in the tobacco), and bone loss around the teeth. The surface of the tooth root may be exposed where gums have shrunken. All this can cause teeth to loosen and fall out.

http://www.cancer.gov/cancertopics/factsheet/Tobacco/smokeless
http://www.cancer.org/cancer/cancercauses/tobaccocancer/smokeless-tobacco  
http://www.nlm.nih.gov/medlineplus/smokelesstobacco.html 

Quitting resources:
http://www.nidcr.nih.gov/oralhealth/Topics/SmokelessTobacco/SmokelessTobaccoAGuideforQuitting.htm 

LOCAL: http://pfh.org/tobacco-cessation/

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Name: Sherman “Red” Yoder
Age: 80M

HPI: This 80 yo male widower from Edina, MO, presents to Blessing Hospital with c/o feeling fatigued. This T2DM patient taking insulin noticed a sore on his Right great toe 3 weeks ago. Treated x 1 week by home health nursing and antibiotics. Admits poor compliance with antibiotics. Treated primarily with soaks. Saw PCP in Edina who sent patient to BH for admit. 

PMH:
Illnesses: T2DM x 6 mos
Injuries: Injured his back lifting hay bales in 1990
Hospitalizations: Back surgery 1990, Croup as a child (c.1940)
Surgeries:  L4-L5 laminectomy c. 1990, TURP- c.2008
Medications:

• Metformin 1000 mg PO BID
• Insulin Lantus 10 Units SQ QD x 1 month
• Benadryl 25-50 mg at HS prn insomnia
• APAP 1000mg prn 

Allergies: NKDA
Prevention:

• Diet “anything I want” at home
• Colonoscopy 5 years ago was “fine”
• UTD on pneumovax, TD and gets annual flu shot
• DRE with OB annually

Personal/Social History: 
Occupation: retired farmer, served in armed services
Marital Status: Widower x 10 years after married 50 yrs
Support: Lives alone, son and daughter-in-law help with farm chores
ETOH: “couple of beers” (3-4) each night
Tobacco: never smoked. Does chew tobacco.
Illicit drugs: denies
Family History: Son, “Jon”, age 53- alive and well, Grandkids: several A&W

Review of Systems:
Constitutional: + insomnia described as trouble getting to sleep- onset 4-5 months ago. Denies fatigue, weight loss/gain, fever, chills, night sweats.
Eyes: +bifocals to read. Denies vision change, pain, redness.
ENT: Denies headache, hoarseness, sore throat, epistaxis, sinus symptoms, hearing loss, tinnitus. Has noticed “lump” under right jaw.
Skin: Denies rash, pruritis.
CV: Denies chest pain, edema, PND, orthopnea, palpitations, claudication.
Pulm: Denies cough, SOB, wheezing, hypersomnolence.
Breast: Denies pain, mass, discharge.
Endocrine: Denies polyuria, polydipsia, polyphagia, heat/cold intolerance.
GI: Denies Abd pain, stool changes, N/V, diarrhea, constipation, heartburn, blood in stool, melena.
GU: Denies Dysuria, frequency, hematuria, discharge, menstrual probs.
MSK: Denies arthralgia, arthritis, joint swelling, myalgias, back pain.
Neuro: Denies weakness, seizures, peraesthesias, tremor, syncope, + Falls x 2 in past several months, memory loss.
Psych: Denies anxiety, depression, hallucinations, +”feels sad” when he thinks of wife.
Heme/Lymph: Denies bleeding, bruising, clotting, transfusions, lymph node swelling
Allergy/Immunology: Denies hayfever, insect allergies, environmental allergies.

Physical Exam:

• BP: 126/74
• P: 84 regular
• R: 14 unlabored
• T: 99.7
• O2Sat: 98% on RA

General: A&Ox3, cooperative and pleasant affect,

HEENT:
Eyes: PERRL, EOMI, Fundi without lesions, AV-nicking, normal disc; sclerae anicteric; conjunctivae pink
Ears: nl EACs with mild cerumen bilaterally, TMs pearly grey with normal mobility
Nose: nares patent, nasal mucosa pink, no d/c
Mouth: with pink moist mucosa, 1 cm lesion rt side of tongue, pharynx non-erythematous
Neck: supple, POSITIVE right submandibular lymphad- mobile, NT mass 1-2 cm in size, no bruits, thyroid symmetrical without enlargement or tenderness
CV: RRR without MRG. Peripheral pulses 2+ and equal bilat in upper and lower exts; normal hair distribution on calves; no bruits
Pulm: Lungs CTAB without adventitious sounds
Abd: Soft and NT without HSM; No scars or lesions
Exts: no clubbing, cyanosis or edema, full NT ROM all exits. 10 gm monofilament 0/10 bilaterally. Vibratory sense intact bilat feet
Skin: 1x 2 cm wound medial rt grt toe, mild erythema, mild exudate, 
GU/Rectal: Perianal external normal, Normal tone, formed brown stool neg for OB. Uncircumcised male with no lesions or d/c; Testicles symmetric, NT, no masses. 
Neuro: CN II-XII grossly intact. Full equal strength and sensation bilaterally. Romberg negative. DTRs 2+ and eq bilaterally

Patient Name: Yoder, Sherman “Red” 
Reason For This Admission: Open wound R great toe, Sepsis, Type II DM
PMHx: L4-L5 Laminectomy (1990, approx.); TURP (2008, approx.)

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S: “I have to get strong so I can return home.” “I need to be able to take care of myself. I don’t want to burden my son anymore.”

O: History: Patient diagnosed with DM 6 months ago and began using insulin 1 month ago. Patient developed a wound on the right great toe 3 weeks ago and was being seen by home health nursing. Wound regressed and patient admitted to hospital with sepsis.

Social: Patient lives alone in a farm house. Patient cooks all meals and obtains fresh eggs from chicken coop every morning.  Son and daughter-in-law live close by and assist patient when needed, including caring for farm animals. Patient visits with friends 1x/week at VFW. Patient ambulates without an assistive device. Patient reports he quickly gets tired when walking. Patient reports falling twice in past month when he “got up too quickly”.  

Cognition: A & O x 3. Follows directions throughout session.

Sensation: Patient unable to feel the 1gm and10gm monofilaments but can feel the 75gm monofilament on bilateral feet.

Motor: AROM bilateral LE: WNL. Strength: grossly 3/5.

Balance: One-legged stance test with eyes open is 10 seconds and with eyes closed is 2 seconds.  

Mobility: Bed mobility: Independent. Patient complained of mild dizziness when transitioning from sit to stand, dizziness resolving quickly. Ambulated with a slow gait pattern 75 feet using front wheel walker. Moderate assist required to help patient maintain non-weight bearing on ulcer. Two standing rests needed due to fatigue. No loss of balance when walking. Patient had difficulty limiting weight bearing through ulcer. Stairs/steps not assessed. Patient tolerated sitting in chair x 30 minutes.  

Wound: Located on medial right great toe. Wound measures 1.0cm x 1.5cm and surface area is 1.5cm2. Wound edges are callused. Wound bed is 50% yellow necrosis and 50% pale pink viable tissue. Minimum exudate. Erythema noted around peri-wound.

A: Major impairments and activity limitations include:

1.    No protective sensation bilateral feet
2.    Neuropathic ulcer on weight-bearing surface
3.    LE weakness
4.    Impaired balance
5.    Reduced gait speed
6.    Difficulty not placing weight through ulcer with ambulation
7.    Limited endurance
8.    Moderate assistance for walking indoors on level surfaces (assistance primarily needed to decrease weight bearing through ulcer)

Goals:

1.    Ambulate 150 feet with 0-1 standing rest breaks using front wheel walker and off-loading shoe on level surface.
2.    Tolerate sitting in bedside chair for at least 1 hour.
3.    Increased LE strength by ½ grade to 3+/5 for increased use in ADLs.
4.    No complaints of dizziness when transitioning from sit to stand.
5.    One-legged stance test will improve to 14 seconds with eyes open to decrease risk for falls.

P: Therapeutic exercise and mobility training QD-BID x 3-5 days. Progress sitting tolerance and distance walked. Patient and family education. Discharge planning. Patient would benefit from an offloading shoe to enable patient to ambulate while also offloading ulcer for wound healing.  Order needed equipment (e.g. FWW; off-loading shoe)

Claudia Sutton, PT

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Patient Name:  Yoder, Sherman
Reason For This Admission:  Open wound R great toe, Sepsis,  IDDM
Reason For Referral: Pt is not meeting nutritional needs complicating diabetic status.
PMH:  L4-L5 Laminectomy aprox  1990, Prostate surgery/TURP , approx 2008

S: “It’s my toe, not my mouth.” when the therapist introduced herself as a speech/language pathologist. He was ask if he was having trouble eating and he responded “Oh yeah, that. - O.K.” The Pt was referred by physician and dentist who indicated the Pt was not meeting nutritional needs and nursing suspected the Pt has  painful chewing. It was noted that social work indicated some possible cognitive and OT indicated the MOCA score suggested mild cognitive impairment.

O: Client’s chart was reviewed and discussed with nursing Pt’s PO intake. A bedside dysphagia eval was completed.

Oral/peripheral exam findings were as follows: All oral/motor structures were WNL for symmetry, ROM, tone, strength, and coordination. The Pt’s teeth are adequate for mastication. His soft and hard palate have a normal appearance. It was noted that there was a significant lesion on the right lateral tongue with some extension into the R lingual alveolar sulcus. His voice was WNL for his age and gender and he was able to vary his pitch and loudness readily suggesting adequate airway protection.

Clinical Bedside Swallowing Assessment Findings:
Observations: The Pt was A & O and able to self-feed. He was cooperative and followed directives throughout the session.
Reports by Patient, Family and Staff: Nursing reports that the Pt is not meeting his nutritional or hydration needs in order to maintain his healthy glucose levels. He is consuming less than half of his meal trays. The Pt’s daughter-in-law was present during the eval and indicated   that she had not noticed any issues with his eating, but she was not always with him during meal times.
Examination by the Pt’s physician and then by a dentist indicated the Pt had a lesion on the R-lateral side of his tongue. When ask why he was having trouble eating the Pt denied pain at first, but then admitted to having pain when consuming food or liquid.
Nourishment Intake Status: The Pt is currently on a regular texture diabetic diet with thin liquids. At home the Pt reports that he eats “whatever” he wants that is available and easy to fix.

PO Trials:

• The Pt was able to take a drink of thin liquids from a cup w/o labial loss. His swallow response time was WNL, but there was an audible gulp. 
• He was able to form a bolus with puree texture but utilized an open-mouth posture. Swallow response time was WNL. 
• With solid textures the Pt again utilized an open-mouth posture and took a significant amount of time to masticate the bolus and move it posteriorly. It was noted there was residue in the alveolar sulcus suggesting difficulty forming a cohesive bolus. The swallow response time was WNL. 

A: The Pt is demonstration an oral phase dysphagia as indicated by uncoordinated bolus formation and residue in the oral cavity after the swallow response had occurred. Difficulty is probably due to painful mastication as a result of the observed lesion. There is a risk of aspiration after the swallow response due to residuals in oral cavity. There are no clinical signs of aspiration at this time (temperature spikes, “wet” lung sounds).

P:

1. Complete the St Louis University Mental Status Exam (SLUMS) to determine if the Pt will be able to follow directives on safe swallowing. 
2. Recommend a Videofluoroscopic Swallowing Study (VFSS) to establish a baseline and R/O aspiration. 
3. Provide the Pt and his caregivers with a list of strategies for safe and less painful swallow (see below). 
4. Recommend that the Pt be placed on a soft texture diet.
5. Continue to monitor for changes in status of the oral cavity. 

  Recommended swallow strategies to decrease painful episodes:

1. tilt head to the left in order to direct material away from lesion site.
2. after each bite take a sip of thin liquid to clear oral cavity.
3. avoid salty and spicy foods
4. adhere to diabetic diet            

Ida Best CCC/SLP

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