Create a FARM Note addressing this patient’s Inflammatory Bowel Disease and pneumonia which is my main case, but please do both. Please, I have uploaded the rubric, each case, and the sample you can follow. please no plagiarism. I will attach the samples and rubric to be followed.
FARM NOTE EXAMPLE
Findings: Subjective- JT is a 67-year-old AA female who presented to the ED 3 hours ago as she
complained of shortness of breath, weakness, fever, chills, chest tightness, a productive cough, and
greenish-yellow sputum for the last 7 days. She was prescribed a Z-pack at a Minute Clinic 5 days ago,
but stopped taking it when she felt better after 2 days. Past medical history is significant for COPD,
emphysema, obstructive sleep apnea, CAD, HTN, and atrial fibrillation. JT’s medications include
pantoprazole 40 mg daily, aspirin 81 mg daily, amiodarone 200 mg daily, albuterol rescue inhaler,
tiotropium 10 mcg inhalation daily, oxygen ~2L daily, metoprolol succinate 25 mg daily, lisinopril 5 mg
daily, atorvastatin 20 mg daily, Tessalon 100 mg three times daily PRN, and guaifenesin ER 600 mg twice
daily. Also, she was prescribed Advair 3 months ago, but admits she does not take it as, “it didn’t work
when I couldn’t breathe.” JT has Medicare and Medicare Part D insurance, has allergies to penicillin
(rash), sulfa (hives), and NSAIDs (upset stomach), and is up to date on influenza, Tdap, varicella, Zoster,
and MMR vaccines.
Objective- Following supportive care in the ED, JT’s vitals were: BP 153/69, HR 85 bpm, RR 24, Temp
100.2°F, SpO2 95% on 2L/min via nasal cannula; JT is 5’3” and 72 kg with a BMI of 28 (overweight).
Physical exam reveals low-pitched, bilateral expiratory wheezes with bilateral opacities in lower lobes
consistent with pneumonia confirmed by chest x-ray and chest CT with contrast, which also showed a
normal heart size and no evidence of pulmonary embolism. Other physical exam findings were normal.
The EKG had a normal rate and rhythm, a prolonged QTc (523 ms), and a low voltage QRS. Labs show
BUN 32, SCr 1.6, WBC 11.7, Hgb 12.1, Hct 35%, Plt 220, and Glucose 189 mg/dL, with all other labs
within normal limits. Her current CrCl using an adjusted body weight is 32 mL/min. After the emergency
physician’s evaluation, she was diagnosed with a COPD exacerbation secondary to pneumonia. In the
ED, JT received methylprednisolone 60 mg, azithromycin 500 mg IV, vancomycin 1250 mg IV, cefepime
1gm IV, morphine 5 mg IV for chest pain, Duoneb every 6 hours, and oxygen via nasal cannula. On the
medical floor, the physician continued the orders for methylprednisolone 60 mg every 12 hours, Duoneb
every 6 hours, azithromycin 500 mg daily, and oxygen. Preliminary sputum culture and sensitivity results
include a gram stain revealing many gram positive cocci chains, and culture data is still pending.
Assessment: Upon assessment, JT has an acute COPD exacerbation secondary to acute community
acquired pneumonia with suboptimal empiric antibiotic therapy secondary to medication nonadherence
as evidenced by cough, increased green sputum from baseline, and radiographic imaging. Goals for this
patient are to optimize the patient’s antimicrobial regimen within 6 hours, resolve signs and symptoms
of pneumonia within 48 hours, and prevent mortality. Based on JT’s comorbidities and medications,
already prolonged QTc interval, and preliminary sputum culture data, alternative antimicrobial therapy
is warranted. Upon presentation to the ED, JT had a CURB-65 score of 3, indicating that JT requires
inpatient treatment for community-acquired pneumonia.1,2 In addition to physical exam findings and lab
data, JT’s emphysema, COPD, and nonadherence to medications are risk factors for pneumonia.1,2,3
Although COPD is a risk factor for P. aeruginosa infection, gram stain results of gram positive cocci in
chains help to rule out P. aeruginosa. Also, JT’s age, COPD, and recent incomplete antibiotics use are risk
factors for drug-resistant S. pneumoniae, warranting dual therapy.1,3 Azithromycin should be avoided in
this patient as it may have an additive effect with amiodarone on JT’s QTc interval, which increases the
risk of Torsades.
Recommendations: Discontinue azithromycin and initiate doxycycline 100 mg twice daily and
ceftriaxone 1 gm twice daily for 5 days.1,3 Will narrow antimicrobial therapy based on patient response
and final culture and sensitivity data.1,3 JT should receive pneumococcal vaccinations: PCV13 at
discharge and PPSV23 in one year.1,3 Collect information regarding smoking history and assess
willingness to quit using motivational interviewing if applicable. Review insurance coverage of inhalers
to ensure there are no economic barriers to pharmacologic therapy. To prevent future COPD
exacerbations and pneumonia, counsel the patient on medication adherence and inhaler technique
using the teach-back method.
Monitoring: Follow up on culture results daily until organism and sensitivities are final.1,3 Assess
therapy’s efficacy by monitoring vitals and improvement of patient’s symptoms, continuously over the
next 48 hours.1,3 Throughout treatment, monitor for adverse effects such as rash, photosensitivity,
allergic reaction (especially with concern of cross-reactivity of cephalosporin and penicillin), and
increased QTc prolongation. Follow up with JT on medication adherence and inhaler technique as an
outpatient.
References
1. Mandell LA, Wunderink RG, Anzueto A, et al. Infectious diseases society of America/American
thoracic society consensus guidelines on the management of community-acquired pneumonia in
adults. Clin Infect Dis. 2007;44:S27-72. DOI: 10.1086/511159.
2. Yearly DM, Fine MJ. (2019). Community-acquired pneumonia in adults: Assessing severity and
determining the appropriate site of care. In: JG Bartlett, JA Ramirez, S Bond (eds). UpToDate.
3. Musher DM, Thorner AR. Community-acquired pneumonia. N Engl J Med. 2014;371:1619-28.
DOI: 10.1056/NEJMra1312885
FARM Note Example
Case Prompt
Chief Complaint: “I can’t breathe!”
HPI: JT is a 67-year-old African American female who presented to the ED from home three hours ago
complaining of shortness of breath, chest tightness, generalized weakness, subjective fever and chills,
and a 7-day history of productive cough with increased sputum production from her baseline. Five days
ago, she visited the local Minute Clinic to receive treatment for what she presumed was an infection.
She was prescribed a Z-Pak. She stopped taking her Z-Pak two days later when she “felt better.” Since
then, the patient’s shortness of breath has worsened, and she is now experiencing chest tightness.
Because her condition was not improving, she presented to the hospital for further management. She
notes that her sputum is a greenish-yellow in color instead of the usual white-grayish sputum associated
with her COPD. The patient reports that she has experienced some fevers and chills at home, but she
did not check her temperature. When questioned about her home medications, the patient reports
that she was recently started on Advair® as an outpatient approximately three months ago, but has not
been taking it because “it didn’t work when I couldn’t breathe!” Following emergency physician
evaluation, the patient was diagnosed with a COPD exacerbation secondary to presumed pneumonia.
She was then stabilized and transferred to the medical floor for further evaluation and management.
PMH: GERD (x6 years), COPD (x9 years), emphysema (x9 years), obstructive sleep apnea (x1 year), CAD
(x14 years), HTN (x14 years), atrial fibrillation (x1 year)
SurgH: right total knee arthroplasty (10 years ago)
FH: mother died from ruptured brain aneurysm (age 56), father was killed in a fire (age 67)
SH: married; lives at home with husband; patient has complete medical coverage through Medicare and
a Medicare Part D supplemental insurance
Allergies: penicillin (rash), sulfa (hives), NSAIDs (upset stomach)
Home
• Medications:
Pantoprazole 40 mg PO once daily
• Aspirin 81 mg PO once daily
• Amiodarone 200 mg PO once daily
• Albuterol 2 puffs q4-6h prn shortness of breath
• Tiotropium bromide 18 mcg inhalation once daily
• Fluticasone-salmeterol Diskus 500/50 inhalation twice daily
• Oxygen (~2L daily)
• Azithromycin 500 mg PO on day 1 followed by 250 mg once daily for 4 days
• Metoprolol succinate 25 mg PO daily
•
•
•
•
Lisinopril 5 mg PO daily
Atorvastatin 20 mg PO once daily
Tessalon® 100 mg PO three times daily as needed
Guaifenesin ER 600 mg PO twice daily
Vaccinations: Up to date on influenza, Tdap, varicella, Zoster, and MMR vaccines
Review of Systems: Patient is experiencing shortness of breath, a productive cough with green-yellow
sputum, subjective fever/chills, and pleuritic chest pain that is “right in the middle of my chest.” She
denies any nausea, vomiting, constipation, or problems urinating.
Physical Examination:
•
•
•
•
•
•
•
•
•
•
•
•
•
Height / Weight: 5’3” / 72 kg
Vital Signs
o On presentation to the hospital: BP 162/65 mmHg, HR 82 bpm, RR 31 rpm, Temp 99.3°F,
pulse ox 94% on 2 LPM oxygen via nasal cannula continuously.
o After supportive care in the ED: BP 153/69, HR 85, RR 24, Temp 100.2°F, SpO2 95% on 2
liters per minute via nasal cannula.
Head: normocephalic and atraumatic
Eyes: pupils are equal, round, and reactive to light. Extraocular muscles appear to be intact. No
scleral icterus or redness. No nystagmus.
Oropharynx: Clear. No lesions. Tongue in midline. No abnormal deviations.
Neck: Supple. No JVD, no hepatojugular reflux. No thyromegaly or lymphadenopathy.
Chest: No chest wall tenderness to palpation.
Breasts: Benign.
Lungs: Bilateral scattered low-pitched end expiratory wheezes more heart posteriorly over right
lung.
Heart: regular rate and rhythm, normal S1, S2.
Abdomen: scaphoid in shape. Abdomen is soft, nontender, nondistended. No costovertebral
angle tenderness to percussion. No organomegaly. No costovertebral angle tenderness.
Extremities: Postoperative scar over right knee and over right femur. Two-plus below-the-knee
pitting lower extremity edema. No peripheral clubbing. No cyanosis. No deformities.
Neurologic examination: Benign.
Laboratory Data:
Na
K
Cl
CO2
BUN
132
4.3
111
22
32
SCr
WBC
Hgb
Hct
Plt
1.6
11.7
12.1
35%
220
Glucose 189
Cultures and Sensitivities:
•
Sputum
o Gram Stain: >25 WBC/HPF,