I need this by monday

PATIENT INFORMATION

Patient Name: Rebecca Snyder DOB: 04/24/1953 Address: 1375 Cadburry Lane, St. Louis Park MN 55402

Patient ID: #6700891 Gender: Female Phone: (612) 776-8900

Insurance: Medicare Primary Care Provider: Dr. Vereen, Vila East

Contact Permissions: David Snyder, husband (952) 493-9302 Avi Snyder, son (952) 783-0021

Patient ID: #6700891 Gender: Female Phone: (612) 776-8900

PATIENT HISTORY

H&P: Mrs. Snyder is a 56 year old obese Orthodox Jewish women with a PMH of poorly controlled DM, HTN, hypercholesterolemia, anxiety, and obesity. She admits to the ED with c/o hyperglycemia ranging from 230 to 389 for over 10 days, frequent urination, malaise, and mild abdominal discomfort, dyspnea on exertion and HTN on admission.

Family Hx. Mother: Alive. History of HTN, DM, Dementia. Father: Deceased. HX of MI, Colorectal CA Sister: Alive. HX of Breast CA. s/p right mastectomy.

Meds on Adm: Metformin 1000 mg q hs., Lisinopril 20 mg QD. Prior to adm. Was prescribed anti-anxiety medication but self d/c’d without taper due to c/o fatigue. V/S: 36.7, 102, 171/93, 24. O2 Saturations 92%. On room air.

Neuro: A&O x3. Appropriate responses, anxious. c/o daily H/A with minimal relief with NSIADS. Recent c/o blurred vision. Wears glasses.

Cardio: HRR. Tachycardic. No audible murmurs or c/o CP. EKG normal.

Respiratory: Lung sounds diminished in all fields. Sats 92% on RA. c/o dyspnea on exertion for 6 weeks. See for care at Ferndale clinic. Occasionally sleeps in reclining chair at hs. Obtain CXR.

GU: c/o frequent urination. Per pt. menses have not yet ceased. Menses irregular. Occasional vaginal bleeding duration: 1-2 days.

GI: c/o constipation and abd fullness. Abd. Tenderness on exam. + mild acites. Palpated pelvic mass. c/o tenderness.

POC: CBC, BMP, blood glucose ac/hs. CXR, abd. Ultraound. V/S q 4 hr. Metoprolol 25 mg Q 4 hours for BP over 170/80. Initiate insulin gtt at 2u/hr. Blood glucose check q 1 hr. Consider paracentesis.

ALLERGIES & MEDICATION

Allergies: Sulfa

Medication: #6700891 Metformin 1000 mg po q hs for diabetes Lisinopril 20 mg po qd for hypertension Prosac 20 mg po BID (per pt., self d/c’d due to fatigue) Xanax 0.25 prn anxiety hypercholesterolemia. Pravastatin 40 mg po bid for hypercholesterolemia. Advil 1 tab qd pain

LAB

CBC: RBC: 5.1 HCT: 38.8 HGB: 14.7 WBC: 11.1 MCV: 81 MCH: 31 PLT: 301

BMP: Glucose: 399 BUN: 15 CR: 1.1 Sodium: 138 Potassium: 4.2 Chloride: 106 Co2: 23 Calcium: 11 Protein: 7.9 CA-125-1700 U

PRIMARY CARE NOTES

05/10/19: Abd CT showed multiple liver mass nodules too many to count. Suspected liver metastasis Colonoscopy showed a 3.1 cm colorectal mass. Invading lower intestine. MRI negative for spinal cord or brain lesions. Plan of care: Gynecologic oncology consult. CBC, BMP, CA-125, HCG, AFP, Paracentesis, in am. PT, SW, CM consult.

05/09: Mrs. Snyder is a 56 year old obese Orthodox women with a PMH of poorly controlled DM, HTN, hypercholesterolemia, anxiety, and obesity. She admits to the ED with c/o hyperglycemia over 230 for over 10 days, frequent urination, malaise, mild abdominal discomfort, dyspnea on exertion.

DX: Hyperglycemia, abd. distention & acites, suspected ovarian cancer Called Dr. Hanson-GYN ONC. Consult expected for tomorrow. Suggested CA-124, HCG, AFP prior to consult.

Blood glucose 200 on insulin gtt. POC: d/c Insulin gtt. Begin 30 units of Lantis 1 x a day in am and 10 mg. of Novalog 3 times a day.

05/09: Abd. ultrasound approximately 450 ml of peritoneal fluid. Paracentesis is recommended.

SOCIAL WORK

05/10: Met with Mrs. Snyder on 05/09/19. Mrs. Snyder is a 56 year old obese Orthodox women with a PMH of poorly controlled DM, HTN, hypercholesterolemia, anxiety, and obesity. She admits to the ED with c/o hyperglycemia over 230 for over 10 days, frequent urination, malaise, mild abd. Discomfort, dyspnea on exertion.

On 05/08/19 pt. was diagnosed with Ovarian Cancer. Work-up still in progress to determine stage, although it appears that Mrs. Snyder may have a Stage III or Stage IV ovarian cancer. In addition, Mrs. Snyder has uncontrolled diabetes with blood glucose levels consistently in the 200-300’s. PTA, she was on oral anti-diabetic medication. Will most likely be d/c’d on insulin ac/hs. Will need diabetic teaching, glucose monitoring and support.

Social: Patient lives in a multi-level home with first floor set-up. Resides with husband, 2 teen age children and is primary caregiver for elderly mother with dementia. Independent in ADL’s. Able to walk household distances without AD but requires frequent rest breaks due to fatigue and SOB. Family responsibilities include child care (2 teenage boys) total physical care for elderly mother with dementia, shopping, meal preparation, cleaning, as well as managing the home and business finances. Husband available, however just opened a deli and is unable to assist with household duties.

Mrs. Snyder primary concern is the care for her mother. She has a sister that lives in Florida, but she has not stepped up the plate or offer to care for their mother. Mrs. Snyder has adult children. Her daughter may be of some help, however, she has 2 small children to care for while her spouse works full time. Her son, Avi lives nearby, but she does not believe that he would be able to manage her mothers’ care due to substance abuse issues. Plan: Continue to meet with Mrs. Snyder and discuss discharge options. Discuss case with care coordinator and primary care provider.

05/10: Second visit with Mrs. Snyder to discuss new dx. of ovarian cancer Family member in the room. Patient quiet. Pt. described tx options provided by GYN/ONC. Pt. fearful of pain and discomfort of surgery and stated that she didn’t see that surgery would help her much. Is willing to learn about additional options other than surgery. Pt. became tearful when discussing the side effects of chemotherapy. “I don’t want to be in pain. I certainly don’t want to feel nauseous! I just want to go home! Why can’t I go home?” SW provided support and counseling. Session d/c’d after patient asked SW to leave.

CASE MANAGEMENT

Mrs. Snyder is a 56 year old obese Orthodox women with a PMH of poorly controlled DM, HTN, hypercholesterolemia, anxiety, and obesity. She admits to the ED with c/o hyperglycemia. C/O frequent urination, malaise, mild abd. Discomfort, dyspnea on exertion. Reviewed notes from SW and appreciate team input.

Mrs. Snyder has been newly diagnosed with Stage IV ovarian cancer. She has a large family and circle of friends but desires to manage on her own. Her primary concern is the care of her elderly mother who requires total physical care. Listened to concerns about surgery and chemotherapy. Educated patient regarding potential side effects and what to expect. Answered questions about Radiation. In Ovarian cancer, it is used means of combating pain and involves high energy rays, similar to X-Rays, delivered to affected parts of the body.

DIABETES EDUCATOR

Mrs. Snyder is a 56 year old obese Orthodox women with a PMH of poorly controlled DM, HTN, hypercholesterolemia, anxiety, and obesity. She admits to the ED with c/o hyperglycemia over 230 for over 10 days, frequent urination, malaise, mild abd. Discomfort, dyspnea on exertion.

Previously on Metformin only. Will most likely be d/c on Insulin BID with SSI ac.

Met with patient to discuss dietary needs and restrictions. Mrs. Snyder keeps a kosher household. Family members are lactose intolerant, have nut allergies, and her mother needs to have her meals pureed due to cognitive difficulties that impact her nutritional status. Pt. prepares meals and shops for the family. Pt. makes traditional meals such as roast beef, kugel, and potatoes. Occasional fresh greens, but the majority of fruits and vegetables are canned. Pt. admits to snacking on popped corn salty chips and enjoys chocolate cookies at bedtime.

Plan of Care: Provided Mrs. Snyder with diabetic resources. Diabetic diet and insulin teaching. Would benefit from diabetic nutritional counselling at d/c. Diabetic teaching initiated.

REHAB

Initial-Consult: 05/10 Mrs. Snyder is a 56 year old obese Orthodox women with a PMH of poorly con- trolled DM, HTN, hypercholesterolemia, anxiety, and obesity. She admits to the ED with c/o hyperglycemia over 230 for over 10 days, frequent urination, malaise, mild abd. Discomfort, dyspnea on exertion.

Lives in a multi-level house with 8 STE. One flight of steps to second level. Bed and bath on 2nd level with first floor set up available. Resides with husband, elderly mother and 2 teenage sons.

Independent in ADL’s. Requires additional time due to fatigue and recent SOB.

Household duties include: walking household distances, shopping, meal prepara- tion, cleaning, driving, and providing total care to elderly mother, managing busi- ness and personal finances.

Pt. able to ambulate 50’ without AD, but required HHA due to c/o feeling unsteady. Required seated rest breaks x4 due to c/o SOB and fatigue. Pulse oximeter 91% with ambulation. Returned to chair with pulse oximeter to 92%. In no distress.

Bed to chair transfer: Independent Toilet transfer: Independent.13 steps with frequent rest breaks. Steps: Patient able to ascent/descend LTG: Pt. will walk 200’ without AD independently. STG: Pt. will walk 50’ without seated rest break.

PROGRESS NOTES

Given patient s/s, suspect Ovarian Cancer. Appreciate Gynecologic oncologist consult. To discuss options with patient. Surgery may be an option, however, due to her having stage IV, supportive care, pain and symptom management is more likely through chemotherapy and radiation.

GYN/ONC

Mrs. Snyder is a 56 year old Orthodox women with a PMH of poorly controlled DM, HTN, anxiety, and obesity. She admits to the ED with c/o hyperglycemia over 230 for over 10 days, malaise, and mild abd. Discomfort. Her initial exam revealed and enlarged abd. with pelvic mass. GYN/ONC physical exam: palpable bilateral ovaries with size consistent with radiology.

Radiologic studies revealed: 05/09/19: Abd. Ultrasound approximately 450 ml of peritoneal fluid. Paracentesis is recommended for comfort and disease staging. 05/09/19: Abd CT showed multiple liver mass nodules too many to count. Suspected liver metastasis 05/10/19: Colonoscopy showed a 3.1 cm colorectal mass. Invading lower intestine. 05/10/19: MRI negative for spinal cord or brain lesions.

Blood work: CA-125-1500 U/ml human chorionic gonadotropin (HCG): 6241 alpha-fetoprotein (AFP): 997 Paracentecis lactate dehydrogenase (LDH): Above normal @ 480U/L

Based on physical presentation, blood work and radiology studies, Ovarian Cancer is confirmed. Discuss with pt. treatment options such as surgery and/or Chemotherapy and radiation. Thank you for allowing me to consult on Mrs. Snyder.