Family Medicine in MONTROSE, CO

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Family Medicine in MONTROSE, CO

• Mandy Robar
• January 2007

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Montrose
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Montrose

• Founded 1882
• Population 15,479
• 81 white, 17 Hispanic
• 21 gt65 years old
• 15 below the poverty line
• For every 100 females, 87.2 males

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Mostly known for what its close to

• Black Canyon National Park

• Ouray

• Telluride

• Grand Mesa

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Uncompahgre Family Medicine

• Dr. Tim Sullinger
• Air Force mechanic
• Solo practice
• gt4000 patients
• Electronic medical records

• Hospital rounds
• Clinic days
• EGD and colonoscopy
• Outpatient procedures
• Group call/
• unassigned call

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The Clinic
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The Staff
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The Hospital

• 75 bed Regional Medical Center
• Blood bank
• Cardiology
• Emergency
• Family Center
• ICU
• Radiology

• Med/ Surg
• Surgery
• Outpt Surgery
• Respiratory
• Rehab
• Cancer Center
• Sleep Lab

• Montrose Memorial Hospital

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The Patients

• Ranchers
• Construction
• Small business owners
• Retirees gt65 years old

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Common Health Issues

• HTN
• DM II
• Dyslipidemia
• Arthritis
• CHF
• COPD
• Obesity
• Cancer

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Other Common Health Issues

• URI/ Sore throat
• Asthma/ allergies
• Skin lesions
• Musculoskeletal complaints/ injuries
• GERD
• Pain Management
• Preventive Care/ Well Physical

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Chronic Disease Patient

• R.S. is an 86 year old male who presents to ER
  for increasing SOB over 2 days and anxiety. Pt
  seen 8 days previously in outpatient clinic for
  follow-up of dementia and med review.

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• Increased short term memory difficulties
• Increased agitation/ aggression
• Incontinence
• Variable compliance with medications
• Pt with irregular sleep habits
• Increased falls

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Wife is sole caretaker, has early signs of
dementia, and notes increasing diffculty/ fatigue
in caring for her husband.
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• PMH
• - CHF, EF 35
• - Coronary Artery Disease
• - Anterior MI, CABG in 2004
• - Hypertension x 10 years
• - Atrial fibrillation since 2004
• - Alzheimers Dementia x 3.5 years

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• PSH
• - CABG 2004
• - Hernia repair 1989
• FHx
• - Father died of MI at age 71
• - Mother- asthma, HTN,
• bladder CA age 73
• - Sister- HTN, MI age 78

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• SHx
• - Lives at home in Montrose with wife
• - Retired television/ movie set builder
• - 2 children, Telluride and Olathe
• - Never smoker
• - Minimal EtOH, none current
• - Denies IVDA/ illicits
• - Unknown COR status
• - 1973 VW Beetle

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• Medications
• - Coreg 12.5 BID
• - Lasix 20mg EOD
• - K-dur 20meq daily
• - Mavik 2mg daily
• - Aspirin 81mg daily
• - Coumadin 2.5mg MWF
• - O2 nocturnal _at_ 2L/min

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• - Risperdal 0.25 daily
• - Alprazolam 0.125mg Q8hr PRN
• - Namenda 10mg BID
• - Vitamin E 200mg daily
• - Vitamin C 500mg BID
• - Glucosamine

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• Allergies
• - Penicillin
• ROS (per wife)
• - weight gain in 8 days, fatigue
• - Denies fever, chills, sweats
• - Denies chest pain, palpitations

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• ROS cont.
• - SOB, cough, DOE, denies
• hemoptysis
• - constipation
• - Denies vomiting/ diarrhea, melena
• - incontinence
• - ankle swelling bilaterally
• - anxiety

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• Physical Exam
• - Vitals T98.7 P108 BP 156/94 RR24 Ox 89
  3L
• - Gen AOx1, anxious, mod. resp distress
• - CV irreg irreg, tachycardia, S3, 2/6
  diastolic murmur LUSB
• - Lungs Bilateral wet crackles and decreased
  breath sounds at bases, LgtR, accessory muscle use

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• PE cont.
• - Abd distended, firm, mild diffuse TTP
• - Extrem 2 pitting edema to the knees
• - Neuro MMSE 19

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• Labs
• BMP- K 3.0 creatinine 2.1
• CBC- WBC- 8.0, HH WNL
• BNP- 94 pg/mL
• Trop- 0.1 (indeterminate) x3
• INR- 1.2
• EKG- no change from previous
• CXR- diffuse interstitial pulmonary edema,
• enlarged heart, cephalization

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A/P

• SOB/Heart failure exacerbation
• HTN
• Renal failure
• Afib/ anticoagulation

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A/P

• Hypokalemia
• Dementia
• Anxiety
• Constipation
• Incontinence

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Issues

• Multiple chronic conditions
• Medication noncompliance
• Ambulation/ safety
• Incontinence
• Anxiety/ Aggression
• Caregiver physical/ mental health
• Living will/ COR status

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Options

• Stay at home, increased assistance, rehab
• Pt to live with son/ daughter-in-law
• Pt to nursing home for respite care
• Pt to nursing home permanently
• Pt and wife to assisted living facility

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Community Resources

• MMH social workers/ discharge planning
• -living will, assisted living
• MMH Cardiac Rehab 3 days/ week
• Alpine home health
• -meds, O2, INR, safety, education
• Church- night monitor
• Meals on wheels
• Alzheimers support group
• Medication assistance- Walmart generic

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Planning for the Future

• Re-evaluate weekly as outpatient
• San Juan Living Center
• Valley Manor NH
• Hospice interview

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