Sunday

162704 Rahmah Khader Awad Al Zahrani

Home Care Team Visit with Nurse Asmaa, Physiotherapist Maria and dietician Khulud.
78 years old female diabetic and Hypertensive with
AF, CKD, Old CVA
Cardiac Pacemaker,
Diabetic Cystopathy,
Cognitive Impairment

Patient was consious, coherrent and cooperative,

On examination
Lungs - Clinically clear
Heart S1,S2
BP -130/ 75 mm Hg,
Pulse - 62/min,
SPO2 - 94 % on room air.
RBS - 455 mg /dl. after some time 383 mg/dl with patient own glucometer.
Complaints of back pain and tiredness.

Advised To maintain good personal hygeine,

Regular Physiotherapy advise
dietary advise given
Frequent change of position.
To continue the same medications.
requested for Lab Investigations..
Patient's son requested for medicines to be renewed.
170309
Elderly lady has Mild DM with H/O Multiple sroke on Metformin 500 D and ?? Linagliptin
Followed at Derma for Phempigoid and recieved a course of Steroid.
BP- Controlled
No new lab or A1C
Patient is wheelchair/Bed bound for Osteoathrritis
Deaf and looks demented, Difficult to asses Mental Satus (Deaf)
Imp- Mild DM / Old CVA/ Demaentia / Phempigoid
Kindly follow her every 3 months for Vitals, Routine labs, A1C and Medication Refil

Patient to Continue F/U with Derma for Phempigoid

until clear from Derma.
76 yrs lady, K/C: DM, HTN, depression, old CVA, hemorrhoids, hearing & speech impairment, bullous
pemphigoid

pt presented with worsen of her skin rash , with icreases in bullea in no. all over the body
including manduble.
pt prescriped predisolon by dermatology, bur the family stopped given it to the pt as they heared

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about the side effect of long use of steriod, she is off steriod for 1 month, after stpping the steriod pt
satred to have the rashes with bullea fomation, no fever, no decrease level of concious,
pt have no cough, no s.o.b, no chest pain, no neuase or vomting, no abd pain
no painful macturation
systemic review unremarkable

Ex:
concious, alert, disoreinted (her base line as per duaghter)
chest: BEAE, clear
CVS:S1, S2, no murmur
Abd: soft, lax, no tenderness
have muliple burst bullea in all limb, no pus discharge, there is rashes

Lab:
wbc: 13.6
Impression:
worsen of bullous pemphigoid with infected bullea

Plan:
For derma consultatin derma
start IV abx
230704
PROGRESS NOTES
60 ys old male
Case of HTN DM on OHG ( Dimicron 60 mg od )Dyslipidemia
Admitted as case of brain stem stroke on 25/11/2017

Hospital course:
He did all stroke work up : and seen by nerology
Ct on 25 No clear acute brain insult.
Old ischemic changes.
Mri on 27/11/2017 : Old brain changes otherwise unremarkable study.
US Doppler carotid artery both of 04.12.2017:
OPINION
No hemodynamically significant stenosis or vascular occlusion
ECHO: EF 60 systolic function G1
Repeated brain CT on 29/11/2017 :
Findings
" There is newly depicted wide area of hypodensity in the lower pons and medulla with hyperdense
basilar artery
" Redemonstration of diffuse subtle bilateral periventricular hypodensity are noted in keeping with
chronic small vessels diseases
" The midline structure are unremarkable
" The demonstrated orbits and the paranasal sinuses are unremarkable
Impression: -

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Newly depicted brain stem hypodensity? Recent infarction suggest clinical correlation

3/12/2017 he develop
Lower lobe pneumonia and aspiration pneumonia received complete course of antibiotics
Respiratory failure and intubated then extubated after improving
Central line Cath induced RT pneumothorax resolved with chest tube , thoracic surgery, surgery was
involved
and he developed resolved contrast induced nephropathy last creatinine .6
Currently he improved clinically and need physiotherapy at home. And to continue on aspirin, anti HTN
medication

MEDICATION ORDERS
Dosage Dispense
Generic Item Drug Frequency Instructions/Notes Duration
Quantity Qty UOM
Take with food or with a full
glass of water to avoid
Acetylsalicylic Jusprin
81 mg tablet Once Daily digestive tract irritation.
Acid (PHCDKOB117)
Acute Myocardial Infarction:
chew tablet.
Take before meals. Do not
take with any food or liquid
Omeprazole Hyposec 40 mg capsule Once Daily
other than water. Avoid or
limit drinking alcohol.
Bisoprolol
Biscor 5 mg tablet Once Daily Take with or without food.
Fumarate
Take on an empty stomach.
Avoid taking with grapefruit,
NIFEdipine Adalat 90 mg tablet Once Daily limes, seville oranges or
grapefruit juice. Avoid
drinking alcohol.
Multivitamins Mixavit 1 tablet tablet Once Daily
Do not break, chew or crush
Twice A extended-release tablet.
metFORMIN Metaphage 500 mg tablet
Day Take with food. Avoid
drinking alcohol.
Linagliptin Trajenta 5 mg tablet Once Daily Take with or without food.

195077
HOME CARE VISIT
80 yrs. old K/C of DM ,HTN , Dementia
K/C of LT ankle nail done 8 yrs ago.
Pt has 2 big bed sores ( one old & clean ,Other superfascial

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Pt on capotril ,gliclazide 80 bid ,statin ,keppra ,Risperdal 1 mg od ,feroglobin .

Pt vitally stable
RBS 231
Plan
-CSM
-PT NEED YRINARY CATHETER
-PT NEED REGULAR PHYSIOTHERAPY
-PT NEED CARE FROM WOUND TEAM
-NEXT VISIT AFTER 3 weeks
101575
Home health care team visit with Nurse Maryam, Physiotherapist Maria and Deitician Khulud.

81 years old female Hyperensive.

with dementia , sjogren disease ,
CAD post CABG / 10 years ,
hypothyroidism , and bedridden.

On Examination patient was consious, coherrent and cooperative.

SPO2 -95% on room air,
BP - 140 /80 mm Hg,
Pulse - 89 /min,
RBS - 106 mg /dl.
Heart - S1,S2 Lungs - clear, Per Abdomen - soft.

Patient complaints of dry mouth and constipation.

passed small ammounts of stools recenly.
requested for renewal of mfedications.
Advised Frequent Change of position,
to continue same medications.

208758
Home Health Care Visit with Nurse Maryam, Physiotherapist Maria and Dietician Osama.

81 years old male bedridden patient for the past 5 years.

Diabetic with BPH and Grade 3 Sacral Bedsore.
Last Admission for Aspiration Pneumonia.
with Foleys catheter

On examination patient was consious, coherrent and oriented.

SPO2 -96% on room air, BP -110 /50 mm Hg, Pulse -94 / min,
RBS - 119 mg /dl
both upper limb and lower limb digits show contractures.
bilateral pedal oedema present with feeble pripheral pulses.

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Heart -S1,S2 Lungs - scattered bilateral crepts/crackles heard.

Patients wife complaints of Insomnia, shouting, agitation and Psychotic behaviour but refuse for
Psychiatric consultation and medications.
Advised Regular Physiotherapy,
to continue same medications.

Monday
223954
HOME CARE VISIT

86 y old pt k/o AF and CVA on medicatio(TEGRETOL ,PARADEXA,ROUSVASTATIN ,BISOPROLOL)

PT VITALY STABLE blp 100/70 so2 96%
ON EX
PT CONCIOUS ,APHISIC WITH COMPLETE RT SIDE HEMIPLEGIA & LEFT SIDE WEAKNESS
CHEST CLEAR
CVS S1 S2
ABD soft ,lax
BACK normal except small laceration around anus
PLAN
-PT NEED REGULAR PHYSIOTHERAPY
-CSM
-NEXT VISIT AFTER 4 WEEKS

169930
Home Care Team Visit.

82 years old female Hypertensive with Atrial Fibbrillation.

Known Anaemic
Received 2 Units of blood transfusion on her last hospital admission.

Patient was afebrile with stable vitals.

SPO2 -98% on room air. RBS -153 mg /dl
BP -120/60mm Hg
Clinical ex
-CVS s1 s2
-Chest clear
-Abd soft lax
No new complaints noted.

PLAN
-CSM

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-Continous physiotherapy
-Next visit after 4 weeks

114780
HOME CARE VISIT IN 6/11/2017

PT IS VITALY STABLE EXCEPT BLP 150/85

PT C/O KNEE &LEG PAIN

PT ON HER TTT REGULAR

PLAN NEXT VISIT AFTER 2 month

Other
79 Y/O female PT ---htn ,,dm
came to ER w h/o BACK PAIN IN RT AND LT LOWER SCAPULAR AREA SINCE 1 WEEK AFTER SITTING
UNDER COLD WEATHER ASS W MOVMENT ,,,NO FEVER ,,,NO LOWER BACK PAIN ,,,NO FEVER

ON EXAMINATION
pt. conscious ,,oriented,

CHEST-- EAE,,NO TENDER

no wheezing or crepitation
RT AND LT LOWER SCAPULAR MS TENDER

CVS--normal heart sound //

regular pulse

no ectopic beat

ABDOMEN --soft, lax

no tender

no organomegally

normal bowel sound

CNS --GCS 15/15

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NO NEUROLOGICAL DEFICIT

NORMAL TONE

POWER 5/5

NO MENINGEAL SIGN

FOR INVESTIGATION
IMPRESSION
MS SPASM
pt refusing x-ray
223275
Home Health Care Team Visit with Nurse Maryam, Dietician Khulud, Physiotherapist Maria and Intern
Osama.

27 years old male Patient who is a known epileptic and Bedridden for past 18 months.
Patient was in coma for approximately 8 months following ? Viral Encephalitis/stroke in USA about 18
months back in 2016.
He has Spasticity of both Upper and lower limbs with Incontinence of Bowel and bladder.
Post Tracheostomy with still open wound ? communicating trachea.
PEG Tube feeding.

On examination patient was consious and cooperative.

with contractures of both wrist joints, hands and feet.
No signs of DVT . No Pedal Oedema
SPO2 -99% on room air,
BP -100 /70 mm Hg, Pulse - 63 /min, FBS - 98 mg /dl.
Heart - S1,S2 Lungs - clear, Per Abdomen - soft.

Patients family requested for renewal of medications

Physiotherapy and diet advice given.
Advised to continue same medications.
162389
Home Health Care Team Visit with Nurse Asmaa, Dietician Khulud, Physiotherapist Maria.

75 years old female known Hypertensive, diabetic with Atrial Fibrillations,

TIA

On examination patient was consious , coherrent and cooperative

BP - 125/75 mm Hg,
SPO2 - 93% on room air,
Pulse - 71 / min,

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RBS - 383 mg/dl
Heart - S1,S2 Lungs - Clinically clear, Abdomen - soft and lax.
Patient has bilateral leg swelling with Pedal Oedema.

Advised Physiotherapy ,
To continue rest of same medications.
As the patient is of Syrian Nationality she will not be Covered by MOH for Home Health Care.
Further care should be at Private Hospital.

Tuesday
225080
Home Care Team Visit

60 years old female Known DM ,HTN.

with Recent Intra Cranial Haemorrhage, Intraventricular Bleed,
Right sided Hemiparesis,
Tenosynovitis of Medial Ligament
Patient complaints of Cough
On examination patient was consious, coherrent and cooperative
PT vitaly stable (bl p 140/60 ,RBS 113 SO2 96)
CVS s1 s2
CHEST harsh vesicular breathing
ABD soft lax
No edema LL
PLAN
-CSM
-ADD AZITHROMYCINE 500 FOR 5 DAYS
-Continu physiotherapy
-------------------
224700
Home Health Care Visit

88 years old male known diabetic and Hypertensive with Ischaemic Heart Disease
he is Bedridden with Fracture of D12 and L1. (using dorsi-lumbar belt)
Fracture of pelvic bone.

On exmination consious ,coherrent, agressive and agitated.

Lungs were clinically clear,
Heart S1,S2
No edema LL
Per Abdomen -soft and lax.
BP -100/60
Pulse - 72/min,
SPO2 94% on room air.
RBS - 180 mg /dl.

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PLAN:
-CSM

---------
127890
Home Health Care Team Visit with Nurse Maryam, Dietician Khulud and Physiotherapy Intern.
56 years old male with Intractable Epilepsy.
known diabetic, hypertensive with Hypothyroidism,
Old CVA and Chronic hyponatremia.
Has recently undergone Surgery for Fracture of left Femur.

On examination patient was consious, coherrent and cooperative.

Patient was agitated and restless.
Vitally stable, BP -150/90 mm Hg,
Pulse -96/ min,
SPO2 -95% on room air.
Heart S1,S2 , Lungs - clinically clear
Patient complained of Constipation.

Advised Syrup Lactulose BID and Tab Bisacodyl 5mg at HS

To continue same medications.
Advised about Physiotherapy and diet
Next home visit after 6 weeks.

176831
HOME CARE VISIT
81 years old male patient Diabetic with Renal Impairment,
Intertrochanteric fracture of Left Femur.
Had Open Reduction and Internal Fixation with Dynamic Hip Screw about 8 months back

On examination patient is consious, coherrent and cooperative.

Bedridden and Afebrile with BP - 120/70 mm Hg,
Pulse -74/ min,
SPO2 -95% on room air.
RBS 63
Chest - Clinically clear, Heart S1,S2 , Abdomen -soft and lax.
RBS -101 mg/dl
No New complaints noted.

Advised Regular Physiotherapy.

to continue same medications.
REGULAR DEIT EVERY 4 hours
-------
123108

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Home health care team visit with Nurse Maryam, Physiotherapist Maria and Deitician Khulud.

81 years old female diabetic with Dyslipedemia and epileptic.

1st to 2 nd grade bedsores in the back with blisters over the lateral aspect of right hip .

On Examination patient was consious, and cooperative.

SPO2 -96% on roomair,
BP -90 /60 mm Hg,
Pulse - 82 /min,
RBS 225 mg /dl.
Heart - S1,S2 Lungs - clear, Per Abdomen - soft.

Patient requested for renewal of medications.

Advised Frequent Change of position,
good care of Bedsore,
Strict diabetic diet and
to continue same medications.

Thursday
214718
HOME CARE VISIT
70 years old male known DM ,HTN.
Chronic smooker and bedridden for past 10 years
Had developed arterial ulcer and dry gangrene of 1st, 2nd and 3rd toes of right foot.
Patient had stent placed in the arterial system of right lower limb at King Fahd Hospital recently.

On EX:
pt consious, coherrent and cooperative.
Heart -S1,S2
Chest clear, Per
Abd - soft and lax
Pt vitaly stable
RBS - 230 mg/dl,
SPO2 - 96% on room air.
Plan
-CSM
-Pt need wound care staff with us in next visit
-next visit after 3 weeks
-Advised strict diabetic diet
-Regular Physiotherapy

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