🚀 go-pugleaf

Here's some more thrown out by some brave souls- c'mon, Nurses, just
the Medics in the game so far! this is my fourth post in the series..

>>Question 1: What further information do you want to try to obtain on
>>the history?
>>
>I would also want to know previous hx of drug abuse (IVDA etc). 
old history of same- heroin in the 70's.
>When his last drink was. 
this am- it's now 1000 hrs, and he looks at the student who is trying
to find out how much he usually drinks and states, "A pint a day!!
Honey, I spill more than that!"

>I would also wan't to know what the sputum looked like, 
already posted

>any associated fever or night sweats ( although doesn't really go with weight
>gain, could be masked by other process). 
none noted, but he drinks to stupor every day.

>I want to know if he is on the streets or in a shelter. 
He's reluctant to admit that he's been thrown out of the shelter three
times already this month for trying to bring his "Tbird" in with him.

>If he has his pill bottles with him or if he
>remembers the names, or ask things like are you on a water pill, etc.
already posted.

>Also how many blocks he can walk before needing to rest, and what his sleep
>position is. 
he walks from lamp post to lamp post usuall, and sleeps where he
spralls

>ASk him if the extremity swelling is new (homeless people often
>have swollen feet).
he's been hospitalized for same several times, see previous post

> I would also go through other HIV risk factor questions.
see previous post

>Also would want to know if any recent trauma.
he has multiple bruises on his arms and legs, as well as excoriated
sores. He denies any recent trauma.

> Also what his stools and urine look like.
"Shit's brown and piss is yellow, ain't it?"
>
>>Question 2: How much can you depend on ....

>It all depends on what kind of relationship you have with this patient. My
>hospital back in NY is considered the Haven for the homeless in lower
>Manhattan, and our ER director is very much an advocate, as a result these
>patients are not treated as the scum of the earth. Many of our regulars
>proudly boast that Bellevue is their hospital. As a result, the staff
>usually has a good relationship with the regulars ( or knows how to work
>around their quirks). So with a little knowledge and experience in working
>with this population, I would believe most of what I got from the patient,
>but assume they are not telling you everything. Most will be honest if asked
>direct nonjudgemental questions. Some words of advise to those reading, when
>I mentioned above checking for HIV risk factors, you have to be very
>specific in your questions. You need to ask things like do you have sex with
>men, do you have sex with men for money, etc. Many vulnerable populations
>will do anything to survive. This patient could be hustling but not consider
>him self gay, so asking the patient if he has homosexual sex will get you an
>honest response but not the info you are looking for.
good points

>>Question 3: What is your working assessment, and what do you want to
>>do while waiting for the doc to arrive and re evaluate the patient?
>
>On first impression (based on the info given and not the answers to the
>questions I would ask), I've got a few things going through my head. First
>I'm thinking maybe CHF and or cardiogenic shock. I'm also thinking maybe TB
>(some of the HX does not go with this, but in my world we have a high
>incidence especially in the homeless pop). I'm also thinking early about
>preventing DT's ( we are very agressive about that back home). While I'm
>waiting around, we'll get the patient undressed (a chance to assess his
>skin, weight status etc). IV kvo and probably get the MVI, folate, thiamine
>ready. I would want another set of vitals (orthostatic's if possible), 
see below
>pulse ox. Have him bring up some sputum. reevaluate his lung sounds. Get a 12 lead
>ECG. put on some O2
see previous post
>>
>>Question 4: What lab work or tests would you want to have ready to
>>roll by the time the doc gets there?
>
>Blood chemistry ( would get measured osmolality ), CBC with diff, pt/ptt, 12
>lead (said before) u/a with micro, urine lytes and measured osmolity, amonia
>level, liver enzymes, rectal guiac.
I like the measured osmols!
others pending

>Good case, can't wait to see what happens next!
just wait!

>Question 1: What further information do you want to try to obtain on
>the history?>>
> Where has he been sleeping?
in a box over a subway grate

>b/  Difficult micturation? Bowel movements? (when, how, painful, etc.?)
strong odor of urine, body and feces about the patient.

>c/  Productive cough?
see previous post

>d/  How "high" up are the rales?  Do lung sounds change with position?
into both axilla, but stronger on the right

>If so, how?  Does SOB increase with positional changes?
pt is moderately orthopneic

>e/  Nausea, vomiting, diarrhea, chest pain,
see prev post
> syncope?
none
>f/   Afebrile, or not?
temp 97.4 oral equivalent via ear probe

>g/  Skin color (oral mucosa, jaundice, etc)?  Scleral color?
skin tones are dark, moderate yellowing of the sclera is unchanged
from previous documentation on the chart.

>h/  Condition of skin overall - sores, etc?
see above

>i/   Orthostatic vitals signs?
semi recumbant 110/60 pulse 100, dangling 90/50 pulse 110, pt unable
to stand due to marked weakness and incoordination.

>j/  Does SOB increase with exertion of any kind?
pt is not capable of significant exertion

>k/  Is the pitting edema normal, worse than normal or new?
he thinks it's about as bad as usual

>l/   What ARE his medications and is he compliant when he has them
see previous, yes, when he can get them

>m/ Allergies?
none

>n/  O2 Sat with and without oxygen therapy?
see previous post

>o/  Is his mentation "normal" for him (ask staff who knows him)
mentation is close to normal, but he is more easily distractable than
usual.

>p/  Is he truly "anorexic" x 2 days or just going hungry?
"Gee, I just can't swallow much- can't breath and eat." he does admit
to being more thirsty than usual.

>q/  Any known STD's?
none known

>r/  Condition of his feet, aside from edema?
multiple ulcers on legs

>s/  Any complaints of "pain" he's not normally used to having?
>     Is his "normal" pain worse?  Any pain at all?
his legs bother him somewhat more than usual.

>t/   Behavioral psych history?  Korsakoff's? (spelling)
He's been on the psych ward before, but usually is let out with out
medications except for a shot once a month or so at the outpatient
clinic. No indication of expressive or receptive aphasia is noted. 
>u/  Does he normally come to hospital with minor complaints, or only when really sick?
he's not known as a frequent flier- and prefers to stay away from the
hospital unless needed- doesn't like being sent to the lock ward.

>v/  Any parasites known or visible?
multple nits in his hair

>w/  What does otoscopic exam show re: ears?  Any infection?
thick, hard cerumen is noted- he resists an ear wash.

>x/  Any Hx of diabetes?
none known

>y/  Ask him----"Do you feel cold?  Do you feel feverish?"
he pulls his coat closer around him and looks over your left shoulder,
"What do you think I am? Crazy?"

>z/  Any overt gum disease, bleeding, signs of infection, broken/rotting
>teeth?
multple stubs are noted when he grins.

>> Question 2: How much can you depend ....

>Depends on who's on duty that knows him, how well previous visits have been
>documented, and whether his mentation has markedly changed according to those
>records and known observers.  My hands, eyes, ears, assessment - 90%.  Old
>stuff - 10%.

>>Question 3: What is your working assessment, and what do you want to
>> do while waiting for the doc to arrive and re evaluate the patient?>>

>Differentials:
>1/  CHF/Cardiac compromise (metabolic issues)
>2/  Secondary respiratory infection
>3/  Underlying liver disease, possible ascites 2ndary to.
>4/  Renal compromise/shutdown?
>5/  Hypoglycemia, 2ndary to anorexia/starvation?
>6/  Mild dementia (chronic ETOH damage)
>7/  ? Otitis media?  (or, just flat affect and lack of ability to concentrate?)
Oh, oh! got a live one here! Or just some one on the red herrings?

>>Question 4: What lab work or tests would you want to have ready to
>>roll by the time the doc gets there?>>

(can a Nurse do this? )
>Vitals, 12-lead ECG, full bloods, urinalysis, STD screens, ETOH/Tox screens,
>liver function (yeah, I know), blood glucose, ABG's, chest films.  Whew!

pretty consistant on the labs- ABG's are back on 2 Lpm NC- pH 7.35,
pCO2 50, pO2 60, O2 Sat 91%

sorry for the long one- What amazes me is that no one has asked for
the first thing that the doc is going to want to know when he or she
walks into the room........

ck