Progress Notes Printed On Jan 09, 2015

Transcription

1 On November 9, 2014, Grand Junction VA Medical Center Director Marc Magill wrote to U.S. Senator Michael Bennet: We have a qualified provider who administered and monitored the Hepatitis C treatment received by Mr. Holmes. But as the following note from Rodger s medical chart demonstrates, the last providers to monitor and adjust Mr. Holmes complex liver medications prior to his emergency hospitalization by ambulance from home were a primary-care nurse practitioner who had never previously treated Mr. Holmes, and a VA pharmacist. These providers required to provide care beyond their scope of practice had to telephone a pharmacist at the San Francisco VA and a family-practice doctor at St. Mary s hospital for help and advice with this complex and deteriorating patient. The chart note also documents: The unavailability of the GJVA liver specialist The unavailability of Rodger s primary care doctor Rodger s compromised cognitive condition The need for an urgent abdominal ultrasound The lab error earlier that day ( ammonia level pending ) Rodger s emergency hospitalization from home by ambulance at the direction of supervisory physicians ( pt will come in today for further evaluation and poss admission. ) That Rodger continued to be administered dangerous liver drugs until the day of his 10- week hospitalization ( will dc hcv treatment now )

2 LOCAL TITLE: PRIMARY CARE CLINIC FOLLOW-UP STANDARD TITLE: PRIMARY CARE NOTE DATE OF NOTE: JUN 25, ENTRY DATE: JUN 25, AUTHOR: primary-care nurse practitioner EXP COSIGNER: URGENCY: STATUS: COMPLETED *** PRIMARY CARE CLINIC FOLLOW-UP Has ADDENDA *** ESTABLISHED PT-DETAILED VISIT-MEDICAL (99214) HOLMES,ROGER MCKAY 06/25/14 13:45 CHIEF COMPLAINT:f/u hcv HPI:feeling nauseated today, has not been needing mom had a grapefruit today and nothing else,feeling off balance when he stands up and feels dizzy, this might be a little bit worse than it he was seen last week he has not fallen, drinks 5glasses of water a day and boost, when blows his nose may get little bit of blood - it squrts a little bit, confusion is worse because of the nausea still having some blood in the urine, not sure that he has the antibiotics at home diff concentrating unable to read magazine article in the waiting room, + fatigue PMH: Problem List Reviewed ROS: General: heent: CV: No chest pain palpitations resp: Denies shortness of breath cough wheezing GI: Has some bloating that is new since he was seen last week no black or bloody stools stools are soft and loose MSK: Thinks his feet are less swollen today has some compression hose at home has not been wearing them ALLERGIES:PEGINTERFERON Page 2362

3 MEDS:Active Outpatient Medications (including Supplies): Active Outpatient Medications Status ========================================================================= 1) CHOLECALCIFEROL (VIT D3) 1,000UNIT TAB TAKE ONE ACTIVE (S) TABLET BY MOUTH EVERY AFTERNOON FOR VITAMIN D3 SUPPLEMENT 2) IBUPROFEN 400MG TAB TAKE ONE TABLET BY MOUTH TWICE ACTIVE DAILY AS NEEDED FOR PAIN, TAKE WITH FOOD 3) LAMOTRIGINE 200MG TAB TAKE ONE TABLET BY MOUTH EVERY ACTIVE DAY 4) LOPERAMIDE HCL 2MG CAP TAKE ONE CAPSULE BY MOUTH FOUR ACTIVE TIMES DAILY AS NEEDED FOR DIARRHEA 5) NUTRITION SUPL BOOST PLUS/VANILLA LIQUID ADMINISTER 1 ACTIVE CONTAINER AS DIRECTED EVERY DAY FOR NUTRITION 6) OMEPRAZOLE 20MG EC CAP TAKE ONE CAPSULE BY MOUTH ACTIVE EVERY MORNING FOR STOMACH ACID REDUCTION 7) QUETIAPINE FUMARATE 100MG TAB TAKE ONE TABLET BY ACTIVE MOUTH AT BEDTIME FOR THOUGHT CLARIFICATION 8) RIBAVIRIN 200MG CAP TAKE THREE CAPSULES BY MOUTH ACTIVE EVERY MORNING AND TAKE TWO CAPSULES EVERY AFTERNOON FOR 12 WEEKS FOR HEPATITIS 9) RIFAXIMIN 550MG TAB TAKE ONE TABLET BY MOUTH TWICE ACTIVE DAILY 10) SERTRALINE HCL 100MG TAB TAKE ONE TABLET BY MOUTH ACTIVE EVERY MORNING FOR MOOD - TAKE WITH FOOD 11) SIMEPREVIR SODIUM 150MG CAP TAKE ONE CAPSULE BY MOUTH ACTIVE EVERY DAY FOR HEPATITIS C. 12) SOFOSBUVIR 400MG TAB TAKE ONE TABLET BY MOUTH EVERY ACTIVE DAY FOR 12 WEEKS FOR HEPATITIS C. 13) SULFAMETHOXAZOLE 800/TRIMETH 160MG TAB TAKE 1 TABLET ACTIVE BY MOUTH EVERY 12 HOURS FOR INFECTION 14) TAMSULOSIN HCL 0.4MG CAP TAKE ONE CAPSULE BY MOUTH ACTIVE EVERY DAY FOR PROSTATE - THIS REPLACES DOXAZOSIN Medications reviewed with patient and reconciled VS: TEMP:99.2 F [37.3 C] (06/25/ :39) PULSE:84 (06/25/ :39) RESP:16 (06/25/ :39) B/P:94/58 (06/25/ :39) WT:144.7 lb [65.8 kg] (06/25/ :39) HT:70 in [177.8 cm] (04/12/ :18) PAIN:0 (06/25/ :39) Page 2363

4 OBJECTIVE: 63yo MALE: Very pleasant gentleman heent: Mucous membranes moist neck: No masses heart: rrr lungs: cta abd: Protuberant nontender soft abdomen ext: 2+ ankle edema extending to lower third of shin neuro: Oriented to date time place, does not know the names of his medications, is able to recall the phone number and extension for the social worker, Orthostatics: Supine 102/63 pulse 69 sitting 102/63 pulse 69, standing 94/57 pulse 77 Lab: lab past 2 mos rev'd : Report Released Date/Time: Jun 25, 2014@09:52 CREATININE(serum/plasma) 1.6 H MG/DL =============================================================================== Report Released Date/Time: Jun 23, 2014@12:12 CREATININE(serum/plasma) 1.5 H MG/DL =============================================================================== Report Released Date/Time: Jun 20, 2014@12:12 CREATININE(serum/plasma) 1.2 MG/DL Jun 25, 2014@09:41 HGB 9.8 L g/dl HEMATOCRIT 27.3 L % =============================================================================== Jun 23, 2014@09:42 Test name Result units HGB 11.1 L g/dl HEMATOCRIT 31.1 L % Comment Page 2364

5 Radiology: ASSESSMENT/PLAN: 1.HCV case discussed wtih, PharmD, she contacted San Fransisco hepatology pharmacist and after review it was decided to discontinue ribavirin because of anemia and elevated serum creatinine, Viral load is pending and results will help to determine whether or not to continue treatment also discussed case with family-practice doctor at St. Mary's Hospital as PCP and Dr. liver specialist were unavailable today Urgent abdominal ultrasound-if positive ascites will discontinue treatment Pharmacy will contact home health nurse to remove ribavirin from patient's med box today I am hesitant to give Zofran for nausea due to patient's instability and risk for falls Encouraged patient to drink fluids and boost to avoid dehydration epotien 20,000 units subcutaneously today for anemia Ammonia level is pending Ammonia level, CBC, chem panel Friday given precautions for increasing confusion weakness to er 2. UTI Continue Bactrim All of the above reviewed with patient who agrees with plan. FOLLOW UP:2 days /es/ primary care nurse practitioner NP Signed: 06/25/ :02 Receipt Acknowledged By: 06/26/ :05 /es/ PHARMD, BCPS, CLINICAL PHARMACIST 06/26/2014 ADDENDUM STATUS: COMPLETED us shows mod to large amt of ascites - will dc hcv treatment now, this was discussed withnon liver pt will come in today for further evaluation and poss specialist MD Page 2365

6 admission for confusion, weakness, anemia, elevated creatinine /es/ primary care nurse practitioner NP Signed: 06/26/ :58 Receipt Acknowledged By: 06/26/ :15 /es/ PHARMD, BCPS, CLINICAL PHARMACIST 06/30/ :16 /es/ primary care doctor DO 06/26/ :06 /es/ non liver specialist MD Page 2366