[U4Q] Mary Ellen wants to use an outcome management approach…
Questions
[U4Q] Mаry Ellen wаnts tо use аn оutcоme management approach when managing her ABA clinic staff. According to Reid et al. (2021), what is the first thing Mary Ellen should do when taking this approach to supervision?
Assessment аnd Plаn: HPI: This is а 65-year-оld male patient whо presents with a cоmplaint of a “possible left foot infection”. Pt reports this started about 3 months ago. The affected area is located and isolated to the top of the left second toe and has gotten bigger since it started. Pt reports he sought care at an urgent care where they prescribed him an antibiotic a month ago and this got “a little bit better, but not much”. He was instructed to follow up with his primary care provider, prompting his visit today. Unfortunately, since that visit, the pt reports his symptoms have worsened and never fully went away. Pt states that the area is painful, achy, and has started to turn dark and red in places. He describes the pain as “achy” and “burning”, rating it 5/10 currently. The pain never seems to fully go away and is worse with walking or prolonged standing. He notes the pain is somewhat better elevation of the foot. Elevation seems to help improve the pain. The pain radiates up and down the leg at times. Pt does not recall any specific preceding trauma or cold exposure prior to the onset of this. He reports he thinks he has an infection because there appears to be a wound on the foot that has been present since his symptoms started, 3 months ago. This has been consistently present, only slightly improved after taking antibiotics. As for associated symptoms, the pt also reports intermittent pains in both legs at times, particularly after doing a lot of walking but admits to doing less walking lately because of this. The pains run up and down the lower legs below the knee without other radiation. Additionally, he states that the left leg sometimes feels cool to the touch compared to the right leg. With that, he notes tingling at times in the left leg. No complete loss of sensation reported. No other wounds or skin problems of the legs reported elsewhere. Pt admits to slow healing of scratches on his legs in the past, but nothing like this. Pt denies recent fall/injury or known preceding trauma. Medications: Lisinopril/HCTZ 20/25mg PO daily Carvedilol CR 20 mg PO daily Atorvastatin 40mg, one tablet taken PO at bedtime Tamsulosin 0.4mg, one tablet taken PO daily Daily multivitamin (generic, OTC) – one tablet taken PO daily at breakfast Tylenol 650mg PO 1-2 times daily on occasion for B/L leg pain Allergies: Morphine (causes itching) Past Medical History: Chronic conditions: Primary Hypertension (diagnosed 25 years ago) Hyperlipidemia (diagnosed 20 years ago) BPH (diagnosed 10 years ago) Surgeries: Right Achilles tendon rupture s/p repair 2014 Left radius fracture s/p repair ORIF 2019 Health Maintenance/Immunizations: Up-to-date on most recommended, age-appropriate vaccines including COVID, influenza, Tdap. He has not had a shingles or a pneumonia vaccine. Pt last colonoscopy was 15 years ago at age 50 (no concerning findings reported). Family History: Father: Deceased, age 61 due to heart attack. PMHx included HTN and COPD (he was reported to be a smoker) Mother: Alive, age 75, PMHx includes HTN, high cholesterol Siblings (2): Brother – age 52, alive, PMHx includes: heart attack and high cholesterol Sister – deceased at age 56 due to heart attack Children (3) are all reported to be alive and well. Ages 25 (F), 23 (F), and 20 (M) Social History: Tobacco/Vape: Pt reports 1 PPD use of cigarettes for the last 30 years) Alcohol: Pt reports having an occasional beer 2-3 times per week. Illicit drugs: Pt denies illicit or prescription drug use/abuse currently or recently. Pt admits to prior marijuana use in his 20’s, but none since. Marital/Sexual: Divorced once at age 23, then has been re-married for the last 28 years with three children. Living situation: Lives in a home with his wife in El Centro Job: Recently retired Executive Accounts Manager for the City of San Diego (he worked at this job for 35 years) Hobbies: Spending time with his family, fishing, and growing vegetables in his garden to share with family and friends. Diet: No specific diet followed, normal American diet. Pt states he enjoys eating BBQ at cookouts with his friends Religion: Catholic Sleep: Averages 6-7 hours of sleep per night ROS: General: No more fatigue than usual, but less active than usual due to leg pains No recent weight changes (up or down) No fever/chills or appetite changes Skin: See HPI. +Pt has left foot second toe wound with reported overlying skin changes and discoloration (reported as “dark and red in certain place”). The area is not reported to be hot to the touch. No diaphoresis, jaundice. Head, Eyes, Ears, Nose, Throat (HEENT): No vision changes, no redness, no itching, no tearing, no discharge No ear pain, tinnitus, hearing changes No nasal congestion, sinus pain/pressure No gum bleeding No facial swelling, jaw pain, sore throat, or difficulty swallowing No neck pain, or LAD Respiratory: No SOB, DOE, PND or orthopnea No cough or recent URI symptoms No pain with breathing No hemoptysis Cardiovascular: No chest pain, palpitations No generalized LE edema No syncope or light-headedness Gastrointestinal: No abd pain, distension, or n/v No diarrhea/constipation, no blood in stool or melena Genitourinary: No changes in, or difficulty with, urinating. No polyuria, no nocturia, no hematuria, no flank pain Musculoskeletal: +See HPI. +Left foot pain, particularly at the 2nd toe. The pain waxes and wanes depending on activity. L 2nd toe wound reported. +B/L distal leg pain at times, waxes and wanes. No new weakness or joint pain Neurological: See HPI. +Paresthesias to L foot at times. No numbness, focal weakness. No HA, dizziness, vertigo, or tremor. No confusion Psychiatric: No unusual changes in mood, racing thoughts, grandiose ideas, or paranoia No insomnia or recent lack of sleep No suicidal ideations, auditory or visual hallucinations Endocrine: No heat or cold intolerance, no polyuria or polydipsia Hematologic/Lymphatic: No easy bruising or bleeding, no epistaxis Physical Exam Findings: VITAL SIGNS: Temperature: 36.8°C (98.2°F) Pulse rate: 89 bpm Respiration Rate: 19/min Blood pressure: 145/85 mmHg Oxygen saturation: 97% on room air Weight: 75 kg (160 lb) Height: 182 cm (72 in) GEN: Well-developed, well-nourished male. Afebrile. Appears in no general distress. Alert and oriented x 4, answering questions appropriately. HEENT NCAT, normal conjunctiva and sclera color B/L. PERRLA B/L. EOMI B/L. Fundoscopic exam revealed AV nicking, arteriolar constriction, cotton-wool spots, and yellow hard exudates B/L. Visual fields appear grossly intact B/L. Mucous membranes without dryness or pale coloration. No oral swelling. Oropharynx clear. NECK: No appreciable JVD noted. NML c-spine ROM. No palpable neck mass or LAD. SKIN: See attached photo (below) of pt’s L foot/toes. Skin is warm, dry. B/L LE with thin-appearing, tight skin to distal LEs above the ankles B/L. There is a 0.5 inch round area of ulceration and dark discoloration overlying the dorsal aspect of the 2nd toe. There is mild swelling associated. There is some ecchymoses / purple discoloring to the distal aspect of the 2nd toe beyond the wound. There is some skin flaking surrounding the area, with subtle erythema extending toward the dorsal aspect of the midfoot. No diaphoresis. Left foot: HEART/CHEST: Heart sounds with regular rate and rhythm with S1/S2 heard with notable S4 gallop. Displaced PMI just lateral to MCL and to approx. 6/7th intercostal space. No M/R/G. Chest appears hyperinflated and hyper-resonant B/L. LUNGS: Clear to auscultation B/L with prolonged expiratory phase. No noted increased respiratory effort such as sternal retractions. No wheezing or stridor. PERIPHERAL VASCULAR: No LE edema noted. UE pulses: brachial 2+ B/L, 2+ radial B/L. LE’s pulses as follows: Femoral 2+ B/L, PT 1+ B/L, DP trace on L, 1+ on R. Capillary refill UE’s was