Patient with Trach and Ca

Progress Report

Patient: 60-year-old female

PMHx: Oropharyngeal SCC s/p chemo/radiation with chronic trach, recurrent UTIs, OSA, T2DM, HTN, hypothyroidism, obesity, chronic sacral decubitus ulcer with pain, and PMH of COVID.

Reason for Admission: Increasing dysphagia and dysphonia in the setting of chronic trach.

Interval History:
Patient presents with generalized malaise and unwell feeling. She was evaluated by SLP with unremarkable modified barium swallow and by ENT with unremarkable laryngoscopy. Both consultants feel she is at her baseline. Dysphagia and dysphonia appear stable, and she is tolerating a pureed/thin diet. She likely can be discharged tomorrow pending clinical stability.

Problem List and Plan:

1. Dysphagia / Dysphonia

   • ENT consulted; patient at baseline.

   • SLP consulted; MBS not impressive.

   • Pureed/thin diet ordered per previous admissions.

   • Anticipate discharge tomorrow.

2. Dysuria / Urgency

   • UA not concerning for acute UTI.

   • History of ineffective trial with Mirabegron (Myrbetriq 

   • Urogynecology appointment scheduled for.

   • Start Pyridium × 3 days.

3. Class III Obesity / Hypertension

   • Increase amlodipine to 7.5 mg tomorrow.

   • Continue carvedilol.

4. Hypothyroidism

   • Continue levothyroxine.

5. Type 2 Diabetes Mellitus

   • Recent HbA1c 7.8%.

   • Continue metformin.

6. Chronic Lower Back and Knee Pain

   • Long-standing oxycodone prescription, reviewed in PDMP (30 mg tablets, 12/day, last refill).

   • Continue oxycodone 60 mg Q4H PRN.

   • Toradol available for breakthrough pain per patient request.

   • Continue gabapentin.

7. Abdominal Wall Rash

   • Likely candidiasis, currently controlled with nystatin powder.

   • Continue nystatin powder.

   • Hold oral fluconazole.

   • Maintain skin folds clean and dry.

8. Peri-Stoma Rash

   • Dry skin and scaling; no evidence of cellulitis.

   • Schedule daily bacitracin ointment prophylactically, avoid direct application to trach.

9. Stage II Sacral Decubitus Ulcer

   • Continue offloading.

   • Continue Mepilex dressing and daily cleansing.

Comorbidities Present on Admission:

• Dysphagia (mild–moderate pharyngeal)

• PMH of COVID

Diet: Dysphagia diet (pureed/thin)

VTE Prophylaxis: —
Medication Reconciliation: Partially complete

Code Status: Full Code

Discharge Planning:

• Expected Discharge Date:

• AM-PAC (RN/PT): 19 / —

• Expected Discharge Location: Home with services

• Barriers: Now s/p MBS and ENT evaluations, likely stable for discharge in AM.

Current Medications:

• Oxycodone 60 mg Q4H PRN

• Amlodipine 7.5 mg daily

• Carvedilol 12.5 mg BID

• Gabapentin 300 mg daily

• Levothyroxine 112 mcg daily

• Metformin 500 mg BID