LTC: History and Physicals

LTC H&P 1

Patient identification:

Name: TY

Date of Birth: x/xx/1942

Location: LTC Gouverneur

Source of information: self

Referral: Surgery department

Date of visit: 11/8/2021

History of Present Illness:

79 year old Asian female with a past medical history significant for paroxysmal atrial fibrillation on Xarelto 20mg daily, coronary artery disease (s/p LAD Stent in 2013), not currently on ASA 81mg, hyperthyroidism (currently euthyroid), HTN, HLD, Sjogren syndrome (on plaquenil), glaucoma (on lotemax and lantoprost), who presented to NY Presbyterian ER due to an episode of loss of consciousness leading to a fall and head strike on 10/26. Patient and son at bedside state that prior to that day, she was alert and oriented x 3 at baseline and had no problems with dizziness or gait. She says that she went to get out of bed and felt some dizziness, and fell. She says that she does not remember the events of the fall, and remembers waking up with her son next to her. Patient states she takes her medication as prescribed, and has been well hydrated and denies any prior similar episodes. Upon arrival at the ED the patient stated she had a worsening headache and appeared to be confused, however was found to have no focal neurocognitive deficits. She denies any incontinence or biting her tongue. A STAT head CT was done and it demonstrated a right subdural hematoma. CT C spine, CT maxofacial and pelvis Xray negative for acute injury. Patient was then scheduled for a craniotomy for subdural hematoma evacuation, and cardiology was consulted for surgical clearance. Xarelto was reversed with Kcentra 1500 units, and patient was admitted to neurosurgery for monitoring. Prior to the procedure a interval CT head was done, which showed increased volume of SDH.

The patient was then taken to the OR on 10/27 for a subdural hematoma evacuation with Dr. Jones, and a JP drain (Jackson-Pratt) was placed, and was then removed later that day. Patient had a post operative CT head done which showed post surgical changes with a new small Intraventricular hemorrhage, for which the patient is being followed up by cardiology. Overall, the patient tolerated the procedure well and received postoperative IV antibiotics as per hospital protocol. Patient was maintained on Keppra for seizure prophylaxis during the admission. The patient remained stable and made floor status, how developed hyponatremia, for which nephrology was consulted and the patient was started on sodium tablets. Patient was then evaluated by physical and occupational therapy and was sent to Gouverneur on 11/8/21 for subacute rehabilitation.

Currently, the patient is alert and oriented to person, place and time and is in no acute distress. She complains of pain along her surgical suture sites, and has some mild dizziness when sitting up from a supine position. She denies any weakness or pain in her upper or lower extremities. She is able to ambulate with a walker, and is tolerating a PO diet. She has mild dizziness but, denies any fever, chills, myalgias, N/V/D, headaches, recent loss of consciousness, numbness or tingling, slurred speech, changes in vision, incontinence, or any localized pain at time.

Pain controlled on PO medications, on standing bowel regimen for constipation prophylaxis. Venodynes for deep venous thrombosis prophylaxis.

Past Medical history:

paroxysmal atrial fibrillation on Xarelto 20mg daily
coronary artery disease (s/p LAD Stent in 2013)
hyperthyroidism (currently euthyroid)
Sjogren syndrome (on plaquenil),

glaucoma (on lotemax and lantoprost)
HTN and HLD

Current medical Problems:

Atrial fibrillation
Hyponatremia

Subdural hematoma
CAD
HTN and HLD

Medications:

Colace: 100mg, 1 capsule PO TID: for constipation prophylaxis

Keppra: 500mg 1 tablet PO q12h: for seizure prophylaxis
Percocet: 325mg: 1-2 tablets PO every 4-6 hours PRN: for post operative pain
Sodium chloride: 1g 2 tablets PO BID: for hyponatremia
Acetaminophen: 325mg 1-2 capsules PO every 4-6 hours PRN: for pain
Xarelto: 20mg for AFib prophylaxis

Amlodipine: 2.4mg once a day for HTN
Atorvastatin: 40mg once a day for HLD
Metoprolol 25mg for HTN
Plaquenil: 200mg once a day: for Sjogren’s syndrome
Lotemax and Lantoprost 0.005% solution for glaucoma

Past surgical history:

LAD for CAD in 2013

Allergies:

NKDA
No seasonal allergies or allergies to any food

Family history:

Father: deceased at the age of 79 from myocardial infarction
Mother: deceased at the age of 82 from breast cancer
Both parents had a history of HTN and HLD

Social history:

TY is a 79 year old Asian female who lives with her son in an apartment building in lower east side Manhattan. She is able to ambulate with a cane or walker at baseline. Patient is semi independent, in that she can bathe and use the bathroom and dress herself, but needs help with grocery shopping and preparing food. The son assists the mother, along with a home health aid that visits a few times a week. Patients states she was married for 45 years, and her husband recently passed away 5 years ago from a stroke. She states she finished high school and college in China, and worked in the textile industry, and retired at the ago of 60.

Patient eats a well balanced diet or poultry, meat, fish, vegetables, grains, and rice. She denies every smoking cigarettes, drinking alcohol or using an illicit substances. She states that her only sexual partner was her husband, and she denies every having any STI. She enjoys watching dramas, knitting and playing with her grandkids. She also tries to be as active as possible, despite having to use a walker. Her activities include taking 20 minute walks daily.

Review of Systems

General: Denies any fatigue, night sweats, fevers, chills, loss or appetite or weakness.

Skin, hair nails: Denies any changes to her skin, aside from the 2 surgical scars. Denies any lesions, changes in color, texture, increased sweating, pruritis or changes in hair distribution.

Head: Admits to mild dizziness and fall with LOC, has some pain to suture sites on head but denies any headache

Eyes: Denies lacrimation, pruritus, visual disturbances, photophobia, decreased visual acuity. Last eye exam about 5 years ago, acuity unknown

Ears: denies deafness, pain, discharge, tinnitus, use of hearing aids.

Nose/sinuses: denies discharge, epistaxis, tenderness, obstruction.

Mouth/throat: Denies bleeding gums, ulcers, sore tongue, sore throat, swollen tonsils, mouth ulcers, voice changes, denies using dentures. Last dental exam about 4 years ago, normal. Denies biting tongue.

Neck: denies localized swelling or tenderness, stiffness, or any decreased range of motion. Thyroid not enlarged

Pulmonary System: denies dyspnea, SOB, cough, wheezing, hemoptysis, cyanosis, orthopnea, or PND.

Cardiovascular System: has a history of AFib, CAD, HTN, and HLD admits HTN. Admits to syncopal episode. But denies any chest pain, palpitations, irregular beats, edema or ankles, or heart failure.

Gastrointestinal System: denies any nausea, vomiting, diarrhea. Patient had mild post-op constipation. Denies any abdominal pain, unusual flatulence, hemorrhoids, rectal bleeding, change in bowel habits, or any signs of obstruction. Colonoscopy was 5 years ago-normal

Genitourinary: denies dysuria, urgency, or frequency. No foley in place in the facility. Denies any nocturia, polyuria, incontinence or any flank pain.

Sexual history: not currently sexually active, denies any history of STIs.

Musculoskeletal: Denies any myalgias, or tenderness. No weakness in all 4 extremities.

Peripheral vascular system: denies any edema or swelling in lower extremities. No hyperpigmentation or varicosities present. Denies any intermittent claudication, trophic changes or cyanosis.

Hematologic System: denies anemia, easy bruising/bleeding, lymph node enlargement, or every having any DVT/PE.

Endocrine System: denies polyuria, polydipsia, polyphagia, heat or cold intolerance.

Nervous system: Admits to loss of consciousness prior to the syncope episode. Denies any sensory disturbance, motor changes, decreased strength, ataxia, slurring of speech, change in cognition or mental status.

Psychiatric System: denies depression, SI/HI, auditory or visual hallucination, anxiety, obsessive/compulsive disorder, ever seeing a mental health professional, psychiatric medications.

Physical Exam

Vital Signs: BP: 134/80 (supine R arm) HR: 76 regular, RR: 16 unlabored, O2 sat: 99% Temp: 98.9 F oral, weight: Wt: 109 lbs, Ht: 61, BMI: 20.6

General: A&O to person, place, time. In no acute distress. Able to recall the events leading up to hospitalization. Patient is well groomed and has good hygiene. Looks stated age.

Skin: Two 6inch lacerations to right scalp, closed with staples, well healing. No other lesions, or skin abnormalities else where in the body. Skin is warm, dry and intact and has good turgor. No nail clubbing or pitting. No cyanosis or jaundice. Hair of average quantity and distribution for age.

Head: well healing surgical scars to R scalp. Mild tenderness to touch. Otherwise, normocephalic, atraumatic, non-tender to palpation.

Eyes: Non icteric, symmetrical OU. No strabismus, exophthalmos, or ptosis. Sclera white, cornea clear, conjunctiva pink. Visual fields full OU. PERRLA, EOM’s intact with no nystagmus. Red reflex intact OU.

Nose: symmetrical, no masses, step offs, lesions, deformities, trauma, discharge. Nares patent bilaterally. Nasal mucosa pink and well-hydrated. No discharge noted on anterior rhinoscopy. Septum midline without lesions, deformities, infection, perforation. No foreign bodies.

Ears: symmetrical and normal size. No masses, lesions, trauma on external ears. No discharge or foreign bodies in external auditory canals AU. TM’s pearly white and intact with light reflex in normal position AU.

Mouth: pink, well-hydrated, intact with no lesions, masses, ulcerations. Gingiva pink, moist, with all teeth present.

Pharynx: well-hydrated. No ulcerations present. No injection, exudates, erythema, masses, lesions, foreign bodies. Tonsils present with no injection, exudates. Uvula pink, no edema or lesions.

Neck: trachea midline. No masses, lesions, scars pulsations. Supple, non-tender to palpation. No nuchal rigidity noted.

Thyroid: non-tender, no palpable masses, no thyromegaly.

Thorax and lungs: chest symmetrical, no deformities, no evidence of trauma. No adventicious lung sounds. Respirations unlabored, no paradoxical respirations, no use of accessory muscles. Lat to AP diameter 2:1. Non-tender to palpation. Lungs clear to auscultation and percussion bilaterally. No adventitious sounds.

Cardiovascular: RRR, S1 and S2 present and distinct, no S3 or S4 or murmurs. Carotid pulses 2+ bilaterally without bruits. No splitting of S2 or friction rub noted.

Abdomen: flat, nondistended, and symmetric with no scars, striae, pulsations noted. Bowel sounds normoactive in all quadrants, no aortic/renal/iliac/femoral bruits heard. Non-tender to palpation throughout. No guarding or rebound noted. No hepatosplenomegaly to palpation. No CVA tenderness noted.

Genitourinary: Exam was denied, and not needed for the assessment. However would have checked for any masses or lesions, any discharge or erythema. Would have also looked at the uterine wall and to check for any cervical changes.

Rectal: Exam was denied. Would have checked for rectal tone, blood in stool, hemorrhoids, lesions, or masses. Stool brown, negative FOBT.

Peripheral vascular: Bilateral lower extremity nontender, and non edematous. 2+ pulse bilaterally for PT and DP pulses. No pitting edema present. No palpable cords or varicosities. No clubbing or cyanosis. Capillary refill is <2 seconds bilaterally.

Neurologic: Surgical scar well healing. CN II-XII intact. Sensation intact to light touch, sharp/dull throughout. Proprioception, point localization, extinction intact bilaterally. Reflexes: 2+ on upper extremities, absent on lower. No tics, tremors or fasciculations.

Musculoskeletal: 5/5 strength with active movement and FROM with flexion, extension, rotation, abduction/adduction in upper. 5/5 strength in lower extremities

Mental status: normal appearance and behavior, speech and language, mood, thought process and content, understands own condition, exhibits good judgment, memory, and attention, and has good cognitive function. Patient denies feeling depressed or down or having any manic episodes, denies ever seeing a mental health professional.

Imaging/blood work:

-no new diagnostic testing done at the subacute rehabilitation center at Gouverneur’s.

Would have ordered: baseline EKG, CBC, BMP, orthostatic BP, electrolytes (to trend NA+)

Assessment

79 year old Asian female with a past medical history significant for paroxysmal atrial fibrillation on Xarelto 20mg daily, coronary artery disease (s/p LAD Stent in 2013), not currently on ASA 81mg, hyperthyroidism (currently euthyroid), HTN, HLD, among others, who presented to NY Presbyterian ER due to an episode of LOC leading to a fall and head strike. On imaging she was found to have a right sided subdural hematoma, and underwent a right craniotomy for SDH evacuation. Patient was then sent to the Gouvernuer’s facility for subacute rehabilitation.

Plan:

Subdural hematoma:

Patient status post right craniotomy.
Post-op CT head scheduled for 11/9
Follow up with neurology, Dr. Smith, about the course of action

Also schedule a post-op follow up with PCP on 11/9.

Hyponatremia:

Continue to monitor sodium electrolyte levels
Repeat BMP labs within 1 week post op.
Take sodium chloride 1 gram tablets, 2 tablets twice a day until electrolyte levels normalize.

Atrial Fibrillation:

Maintain patient on Xarelto
Monitor for an bleeding or spontaneous GI bleed

Seizures:

Keep the patient on Keppra for seizure prophylaxis

CAD:

Continue taking amlodipine, atorvastatin, and metoprolol as prescribed

HTN/HLD

Continue taking proper medications, as above. Also maintain a healthy lifestyle or healthy foods and a good diet.

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LTC H&P 2

Patient identification:

Name: AS

Date of Birth: x/xx/1930

Location: LTC Gouverneur

Source of information: self

Referral: Surgery department

Date: 11/15/2021

History of Present Illness:

AS is a 91 year old male patient with a past medical history significant for stage IV prostate cancer (on Lupron), HTN, Afib on aspirin, and Parkinson’s disease who presented to the ER on 11/10 complaining of diarrhea. As per the daughter, the patient was in his usual state of health until 11/8. At his baseline, patient has 2 soft bowel movements a day, and is alert and oriented to person and place. On 11/8 the patient was noted to have 10 episodes of loose brown stool a day. The stool was nonbloody, and liquidy in consistency. He denies eating anything different then his usual diet (of rice and chicken) or expired prior to the events. The daughter states that the family ate the same thing as the patient, and have been asymptomatic. The daughter states that one day after the diarrhea started, the patient had a syncopal episode at home on 11/9. He was found on the floor of the living room by the home health aide, and the mechanism of the fall, and length of time on the floor is unknown. The patient denies hitting his head or having any injuries from the fall. Patient states that he denies losing consciousness, and says he felt weak while trying to walk to the couch and fell. The patient admitted to having a decreased appetite, and drinking less water since the symptoms started and thinks he could have been dehydrated. He is also having diffuse abdominal cramping, that is intermittent and comes on with the diarrhea episodes. Patient admits to dizziness and weakness but denies any fevers, chills, nausea, vomiting, blood in his stool, or any urinary complaints.

In the ER, a CT abdomen and Pelvis with contrast as done which showed no abdominal pathologies such as perforation or obstruction. A large heterogenous prostate with sclerotic and lytic lesions was noted, consistent with patient’s known metastatic prostate cancer. The patient was admitted to subacute rehabilitation at Gouvneurs on 11/13 for further management of his diarrhea and failure to thrive.

Currently, the patient is at alert and oriented to person and place, as is baseline. He complains of mild diffuse abdominal cramping, and has been refusing solid foods and is on a liquid diet regimen. He currently denies any dizziness, but admits to feeling weak and having decreased energy. As per the nurses notes, the patient has been having a total of 5 loose bowel movements a day. The stool is described as nonbloody and non fatty, without any strong odor. Patient states that the cramping subsides after having a bowel movement. He denies any fevers, nausea or vomiting.

Past Medical history:

atrial fibrillation
Stage IV Prostate cancer: diagnosed in 2018
HTN
Parkinson’s disease (diagnosed in 2017)
asthma

Current medical Problems:

Diarrhea
Syncope and weakness
Failure to thrive

atrial fibrillation
Stage IV Prostate cancer: diagnosed in 2018
HTN
Parkinson’s disease (diagnosed in 2017)

Medications:

Amlodipine 10mg once daily
Aspirin 81mg once daily
Atenolol 25mg once daily
Sinemet 25-100mg tablet once daily

Vitamin D3 1,000U once daily
Finasteride 5mg once daily
Lupron 22.5mg injection
Losartan 50mg once daily
Montelukast 10mg once daily

Torsemide 10mg once daily

Patient is compliant with all medications

Past surgical history:

Appendectomy in 1994
Skin tag removal in 1982

Allergies:

Penicillin- rash
No seasonal allergies or allergies to any food

Family history:

Father: deceased, history of Parkinson’s disease
Mother: deceased, history of breast cancer
Older Brother: deceased at the age of 85 from MI

Social history:

AS is a 91 year old male who lives with his daughter and her husband and 2 kids in a private residence in the lower east side. At his baseline, the patient walks with a cane and is able to go to the bathroom on his own, but is not able to shower on his own. He gets a home health aide 4 days a week to help him with showering, preparing food, and other activities of daily living. The patients states he was married for 50 years, and his wife recently passed away 3 years ago. He is a retired accountant.

Patients states that he eats a bland diet of rice and chicken, with some vegetables. He states he is a former smoker, who quit 30 years ago. He admits to a 20 pack year history. He denies drinking alcohol or ever using any illicit substances. Patient states he exercises minimally, but walks around the house with his cane. He enjoys watching the news and playing with his grandchildren.

Review of Systems

General: Admits to weakness, loss of appetite and fatigue but denies any night sweats, fevers, or chills

Skin, hair nails: Denies any changes to her skin. Denies any lesions, changes in color, texture, increased sweating, pruritis or changes in hair distribution.

Head: Admits to mild dizziness, and prior syncpal episode, but denies any headache or trauma

Eyes: Denies lacrimation, pruritus, visual disturbances, photophobia, decreased visual acuity. Last eye exam about 8 years ago, acuity unknown

Ears: denies deafness, pain, discharge, tinnitus, use of hearing aids.

Nose/sinuses: denies discharge, epistaxis, tenderness, obstruction.

Mouth/throat: Admits to wearing dentures. Denies bleeding gums, ulcers, sore tongue, sore throat, swollen tonsils, mouth ulcers, voice changes. Last dental exam about 6 years ago, normal. Denies biting tongue with syncopal episode.

Neck: denies localized swelling or tenderness, stiffness, or any decreased range of motion. Thyroid not enlarged

Pulmonary System: denies dyspnea, SOB, cough, wheezing, hemoptysis, cyanosis, orthopnea, or PND.

Cardiovascular System: has a history of AFib, HTN. Admits to syncopal episode. But denies any chest pain, palpitations, irregular beats, edema or ankles, or heart failure.

Gastrointestinal System: Admits to mild diffuse abdominal pain and cramping. Admits to diarrhea and loose stool, but denies any nausea or vomiting. Denies any unusual flatulence, hemorrhoids, rectal bleeding, or any signs of obstruction. Colonoscopy was 5 years ago-normal

Genitourinary: Patient has a history of Prostate cancer, but denies any new dribbling, dysuria, urgency, or frequency. No foley in place in the facility. Denies any nocturia, polyuria, incontinence or any flank pain.

Sexual history: not currently sexually active, denies any history of STIs.

Musculoskeletal: Denies any myalgias, or tenderness. No weakness in all 4 extremities.

Peripheral vascular system: denies any edema or swelling in lower extremities. No hyperpigmentation or varicosities present. Denies any intermittent claudication, trophic changes or cyanosis.

Hematologic System: denies anemia, easy bruising/bleeding, lymph node enlargement, or every having any DVT/PE.

Endocrine System: denies polyuria, polydipsia, polyphagia, heat or cold intolerance.

Nervous system: Prior syncopal episode with dizziness and weakness. Denies loss of consciousness. Denies any sensory disturbance, motor changes, decreased strength, ataxia, slurring of speech, change in cognition or mental status.

Psychiatric System: denies depression, SI/HI, auditory or visual hallucination, anxiety, obsessive/compulsive disorder, ever seeing a mental health professional, psychiatric medications.

Physical Exam

Vital Signs: orthostatic BP: 140/52 (supine R arm). 135/60 (sitting right arm) HR: 64 regular, RR: 18 unlabored, O2 sat: 99% Temp: 98.8 F oral, weight: Wt: 145 lbs, Ht: 64, BMI: 24.9

General: A&O to person and place. In no acute distress. Able to recall the events leading up to hospitalization. Patient is well groomed and has good hygiene. Looks stated age.

Skin: No lesions, or skin abnormalities else where in the body. Skin is warm, dry and intact and has good turgor. No nail clubbing or pitting. No cyanosis or jaundice. Hair of average quantity and distribution for age.

Head: normocephalic, atraumatic, non-tender to palpation.

Mouth: pink, well-hydrated, intact with no lesions, masses, ulcerations. Gingiva pink, moist, with all teeth present.

Pharynx: well-hydrated. No ulcerations present. No injection, exudates, erythema, masses, lesions, foreign bodies. Tonsils present with no injection, exudates. Uvula pink, no edema or lesions.

Neck: trachea midline. No masses, lesions, scars pulsations. Supple, non-tender to palpation. No nuchal rigidity noted.

Thyroid: non-tender, no palpable masses, no thyromegaly.

Cardiovascular: RRR, S1 and S2 present and distinct, no S3 or S4 or murmurs. Carotid pulses 2+ bilaterally without bruits. No splitting of S2 or friction rub noted.

Abdomen: flat, nondistended, and symmetric with no scars, striae, pulsations noted. Bowel sounds normoactive in all quadrants, no aortic/renal/iliac/femoral bruits heard. Non-tender to light and deep palpation throughout. No guarding or rebound noted. No hepatosplenomegaly to palpation. No CVA tenderness noted. Guaiac negative.

Genitourinary: No lesions or ulcerations on external genetalia. No erythema or penile discharge. No testicular or scrotal erythema or tenderness.

Rectal: normal rectal tone, no blood in stool, hemorrhoids, lesions, or masses. Stool brown, negative FOBT. Enlarged irregular prostate size, consistent with prostate cancer diagnosis.

Neurologic: CN II-XII intact. Sensation intact to light touch, sharp/dull throughout. Proprioception, point localization, extinction intact bilaterally. Reflexes: 2+ on upper extremities and lower. No tics, tremors or fasciculations.

Musculoskeletal: 5/5 strength with active movement and FROM with flexion, extension, rotation, abduction/adduction in upper. 5/5 strength in lower extremities

Imaging/blood work:

Imaging:

Chest Xray: No focal consolidation, pleural effusion or pneumothorax detected.

CT head without contrast: No evidence of intracranial mass lesion, acute territorial infarct, or intercranial hemorrhage

CT abdomen and Pelvis with contrast: large heterogenous prostate, with extensive sclerotic and lytic lesions, consistent with patient’s known metastatic prostate disease. No signs of any bowel obstruction, ischemia or infarcts.

US Doppler lower extremity: no signs of any venous thrombosis

Lab work:

BMP:

Glucose	106
NA	137
K	3.9
Chlor	1.8
CO2	17.1
BUN	28
CA	8.4
Creat	1.06

CBC+Diff:

WBC	5.6
RBC	3.93
HGB	12.0
hematocrit	35.5
Neut	79.5
Lympho	10.7
Mono	3.8
Eosinp	5.7
Baso	0.3
PLTS	115

Lipase:29

I would have also ordered an EKG and echo (due to the syncope), and I would have done a stool culture test to assess for bacterial/viral etiology of the diarrhea.

Assessment

AS is a 91 year old male with a past medical history of Stage IV prostate cancer, Afib, HTN and Parkinson’s disease who is coming in for 1 week of diarrhea and weakness. Patient had an episode of syncope in the beginning of his symptoms due to weakness and dehydration. He has been admitted to subacute rehabilitation with a presentation and lab findings consistent with viral gastroenteritis and failure to thrive.

Plan:

Viral gastroenteritis/Diarrhea:

Treat symptomatically
Trend CBC and BMP
Obtain a stool culture

Monitor electrolytes and replete
Maintain patient on a BRAT diet or liquid diet

Dehyration

IV fluids to replete fluid level

Replete electrolytes
Fluid resuscitation 500ml bolus followed with LR 75cc/h

Weakness/failure to thrive:

Place patient on standing Tylenol q6h PRN
Physical therapy eval

Discuss with family nursing home placement/ increasing the frequency of home health aide vist

Metastatic Prostate cancer

On pallative care
Lupron injections q3 months (next dose in December)

Continue proscar 5mg daily

HTN/Afin:

Continue amlodipine, Aspirin 81mg, Atenolol
Monitor for any spontaneous bleeding

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LTC H&P 3

Patient identification:

Name: DS

Date of Birth: x/xx/1940

Location: LTC Gouverneur

Source of information: self

Referral: Surgery department

Date: 11/18/2021

History of Present Illness:

DS is a 81 year old Asian male with a past medical history significant for COPD, HTN, Type 2 diabetes, Peptic ulcer disease (gastric and duodenal) who presented to the ED on 11/16 complaining of 1 week of shortness of breath and cough as well as a recent fall and R shoulder injury. Patient also had associated generalized weakness and low grade fevers, with a Tmax of 100.2F. The patient’s daughter states that he has been more confused for the past week then his usual baseline. He is currently alert and oriented to person and place, but at his base line is alert and oriented to person, place and time. She says that he is was in a family gathering recently, and although he has been fully vaccinated for COVID, and wears a mask, others that were present were not, so she is unsure of any possible COVID exposure. Patient’s symptoms started with a cough that was mildly productive, and progressed to generalized weakness and difficulty breathing. He started feeling a subjective fever 3 days ago, for which he was given Tylenol with mild relief. One day prior to going to the ER, 11/15, the patient had a mechanical trip and fall while walking and fell on to his right shoulder, with no head strike or other injuries. He was unable to move his right shoulder, and the family decided to take the patient to the ER for his increased confusion, cough and shoulder injury. He denies losing consciousness or hitting his head. Patient admits to cough, fever, weakness, dyspnea and right shoulder pain but denies any nausea, vomiting, urinary complaints, LOC, or other injuries.

At the hospital a Chest xray and a CT chest was done, which showed a right upper lobe consolidation, and the patient was admitted for community acquired pneumonia and TB was ruled out. Patient was stable on room air, and did not required oxygen. The pulmonary team was consulted and the patient was started on a 14 day course of Augmentin. A right extremity Xray was also done, which showed a right AC joint separation. Ortho was consulted and recommended the patient to maintain non-weight bearing status and was given a sling, and was told to rest and ice the shoulder. Pain was controlled with acetaminophen and patient was discharged to Gouveneur’s subacute rehabilitation for monitoring and observation

Currently, the patient is alert and oriented to person, place and time and is in no acute distress. He still some difficulty breathing with generalized weakness, but states the fevers have resolved. His right arm is in a shoulder sling, and the patient admits to pain with movement, but says the acetaminophen helps with the discomfort. Patient still has an occasional cough, but denies any chest pain, congestion, fevers, or chills. A PCR Covid test was done at the facility, and was negative.

Past Medical history:

COPD
Type 2 Diabates
Peptic ulcer disease (gastric and duodenal)
HTN
Neuropathic pain

Current medical Problems:

Right upper lobe pneumonia
Right upper extremity pain
COPD

Type 2 Diabates
Peptic ulcer disease (gastric and duodenal)
HTN
Neuropathic pain

Medications:

Atenolol 25MG PO once a day
Gabapentin 300mg 1 capsule PO BID
Esomeprazole 40mg once daily
Glyxambi 25-5MG once daily

Januvia 100mg once daily
Metformin 1000mg once daily
Albuterol 2 puffs PRN

Patient is compliant with all medications

Past surgical history:

Denies any surgeries

Allergies:

No seasonal allergies or allergies to any food

NKDA

Family history:

Father: deceased from stroke
Mother: deceased from MI
Younger sister: alive at the age of 72, with a history of diabetes

daughter: alive and well, age of 49, has a history of HTN and diabetes

Social history:

DS is a 81 year old Asian male who lives with his wife and daughter in a second floor apartment in Brooklyn. At his baseline, the patient walks with a cane on right hand and is able to perform mainly all activities of daily living independently such as using the bathroom, bathing, changing, taking medication and feeding himself. He states he has a home health aide that comes 2 times a week to help with groceries and preparing food as well as helping with whatever else he needs. The patient states he has been married for 45 years and has one daughter that lives with them. He is an Army Veteran, and currently spends his time watching TV, going to the library and playing chess in the park.

Patient states he eats a well balanced diet of rice or pasta with chicken and beef and vegetables. He is a former smoker, and quite 20 years ago, having a 35 pack year history. He denies currently drinking alcohol or ever using any illicit substances. He exercises by walking around the park with his cane, and is able to climb the one staircase of their apartment.

Review of Systems

General: Admits to weakness and low grade fevers, but denies any night sweats, fevers, loss of appetite, fatigue or chills

Skin, hair nails: Denies any changes to her skin. Denies any lesions, changes in color, texture, increased sweating, pruritis or changes in hair distribution.

Head: denies any headache or trauma

Eyes: Denies lacrimation, pruritus, visual disturbances, photophobia, decreased visual acuity. Last eye exam about 8 years ago, acuity unknown

Ears: denies deafness, pain, discharge, tinnitus, use of hearing aids.

Nose/sinuses: denies discharge, epistaxis, tenderness, obstruction.

Mouth/throat: Denies wearing dentures, bleeding gums, ulcers, sore tongue, sore throat, swollen tonsils, mouth ulcers, voice changes. Last dental exam about 6 years ago, normal. Denies biting tongue with syncopal episode.

Neck: denies localized swelling or tenderness, stiffness, or any decreased range of motion. Thyroid not enlarged

Pulmonary System: Admits to shortness of breath and cough, denies dyspnea wheezing, hemoptysis, cyanosis, orthopnea, or PND.

Cardiovascular System: has a history HTN. But denies any chest pain, palpitations, irregular beats, edema or ankles, or heart failure.

Gastrointestinal System: denies any nausea or vomiting, diarrhea, or constipation. Denies any abdominal pain. Denies any unusual flatulence, hemorrhoids, rectal bleeding, or any signs of obstruction. Colonoscopy was 5 years ago-normal

Genitourinary: denies any new dribbling, dysuria, urgency, or frequency. No foley in place in the facility. Denies any nocturia, polyuria, incontinence or any flank pain.

Sexual history: not currently sexually active, denies any history of STIs.

Musculoskeletal: Admits to right upper extremity pain. Denies any myalgias, or tenderness. No weakness in all 4 extremities.

Peripheral vascular system: denies any edema or swelling in lower extremities. No hyperpigmentation or varicosities present. Denies any intermittent claudication, trophic changes or cyanosis.

Hematologic System: denies anemia, easy bruising/bleeding, lymph node enlargement, or every having any DVT/PE.

Endocrine System: denies polyuria, polydipsia, polyphagia, heat or cold intolerance.

Nervous system: . Denies loss of consciousness. Denies any sensory disturbance, motor changes, decreased strength, ataxia, slurring of speech, change in cognition or mental status.

Psychiatric System: denies depression, SI/HI, auditory or visual hallucination, anxiety, obsessive/compulsive disorder, ever seeing a mental health professional, psychiatric medications.

Physical Exam

Vital Signs: BP: 115/70 (supine R arm) HR: 70 regular, RR: 20 unlabored, O2 sat: 96% Temp: 99.2 F oral, weight: Wt: 155 lbs, Ht: 65, BMI: 18.9

General: A&O to person, time and place. Thin elderly male in no acute distress. Able to recall the events leading up to hospitalization. Patient is well groomed and has good hygiene. Looks stated age.

Head: normocephalic, atraumatic, non-tender to palpation.

Mouth: pink, well-hydrated, intact with no lesions, masses, ulcerations. Gingiva pink, moist, with all teeth present.

Pharynx: well-hydrated. No ulcerations present. No injection, exudates, erythema, masses, lesions, foreign bodies. Tonsils present with no injection, exudates. Uvula pink, no edema or lesions.

Neck: trachea midline. No masses, lesions, scars pulsations. Supple, non-tender to palpation. No nuchal rigidity noted.

Thyroid: non-tender, no palpable masses, no thyromegaly.

Thorax and lungs: Mild tachypnea, with crackles and rales heard in the right upper lobe. Dullness to percussion, with positive egophony. Increased tactile fremitus. chest symmetrical, no deformities, no evidence of trauma. . Respirations unlabored with no wheezing, no paradoxical respirations, no use of accessory muscles. Lat to AP diameter 2:1. Non-tender to palpation.

Cardiovascular: RRR, S1 and S2 present and distinct, no S3 or S4 or murmurs. Carotid pulses 2+ bilaterally without bruits. No splitting of S2 or friction rub noted.

Abdomen: flat, nondistended, and symmetric with no scars, striae, pulsations noted. Bowel sounds normoactive in all quadrants, no aortic/renal/iliac/femoral bruits heard. Non-tender to light and deep palpation throughout. No guarding or rebound noted. No hepatosplenomegaly to palpation. No CVA tenderness noted.

Genitourinary: No lesions or ulcerations. No erythema or penile discharge. No testicular or scrotal erythema or tenderness

Rectal: normal rectal tone, no blood in stool, hemorrhoids, lesions, or masses. Stool brown, negative FOBT. Prostate is smooth and not enlarged

Musculoskeletal: Right upper extremity pain to palpation and range of motion limited due to pain. Patient currently in a sling. Left upper extremity is 5/5 strength with active movement and FROM with flexion, extension, rotation, abduction/adduction in upper. 5/5 strength in bilateral lower extremities

Imaging/blood work:

Imaging:

Chest Xray: ill-defined right upper lobe lung consolidation may represent pneumonia; however neoplasm is not excluded. Mild diffuse peri bronchial thickening may be secondary to airways inflammation and/or interstitial edema.

CT Chest: no pulmonary embolism noted. Multifocal peri bronchial right upper lobe consolidation noted consistent with pneumonia. Recommend repeat CT chest follow up in 6 weeks to evaluate for improvement/resolution of findings

Right shoulder Xray: Type 3 Rockwood classification acromioclavicular joint injury

CT head without contrast: no evidence of acute traumatic brain injury

Lab work:

BMP:

Glucose	110
NA	138
K	4.3
CL	105
CO2	20.0
BUN	8.0
CA	8.9
Creat	0.8

CBC+Diff:

WBC	8.1
RBC	3.86
HGB	10.9
hematocrit	32.9
Neut	71.4
Lympho	13.1
Mono	11.5
Eosinp	3.2
Baso	0.10
PLTS	481

LFTs

TP	8.1
ALB	3.7
GLOB	4
TBILI	0.3
DBILI	0.2
IBILI	0.1
ALK	172
SGOT	47

Lipid Panel

CHOL	129
LDL	98
HDL	28
TRIG	93
HBA1c	10.9
BNP	74

TB Acid fast stain: negative, no acid fast bacilli detected

PCR COVID-19: negative

Nasopharyngeal swab for influenza: negative

I would have also ordered an EKG and echo, and I would have done a PFT to assess lung function.

Assessment

DS is a 81 year old Asian male who has a PMHx of COPD, Type 2 DM, PUD and HTN who comes in after 1 week of shortness of breath, generalized weakness and cough and right upper extremity pain after a mechanical fall. Chest Xray, physical exam and labs are consistent with a right upper lobe consolidation, most likely due to pneumonia. Patient also came in with a right upper extremity sling due to a recent trip and fall leading to a right AC joint dislocation, which is controlled with a sling, rest and ice.

Plan:

Right Upper lobe consolidation:

Outpatient follow up with pulmonologist

Patient found to have right upper lobe consolidation, continue follow up labs and imagine
Continue Augmentin for a total of 14 days
Take probiotics along with medication
Repeat CT chest in 4 weeks, if not improvement of consolidation, schedule a biopsy
Trend CBC and BMP

Obtain a stool culture
Monitor electrolytes and replete

Recent fall and RUE pain/ right AC joint separation:

Right shoulder Xray consistent with AC joint dislocation.

Follow up with ortho outpatient
Continue wearing right upper extremity sling and limit movement and weight lifting with that arm.
Rest and ice
Pain control with Tylenol PRN
Physical therapy for training left hand to use cane while the right arm is healing

COPD:

Continue monitoring O2 levels, with a goal of 92%,
Start patient on albuterol HFA 108 MCg/ACT 2 puffs q6h PRN and Trelegy ellipta 1 puff daily for 30 days PRN

Educate patient on proper inhaler use

Diabetes:

Continue regimen of Glyxambi, Januvia, and Metformin
Recent A1C of 10.9%

Continue taking gabapentin for neuropathic pain
Monitor renal function

HTN

Continue Atenolol as prescribed

Peptic ulcer disease:

Continue taking Nexium as prescribed
Routine colonoscopy

Discuss possible endoscopy with PCP