Chief Complaint: “I’m feeling lousy.”

HPI:

AP is an 86yo White Female with PMH HTN, HLD, NPH, Dementia, GERD, PPM for Atrial Fibrillation (2003) who presented to New York Presbyterian Queens ED on the morning of 10/12/19 complaining of head pain, facial pain, and right rib pain following a fall from standing. The patient reported that she did not experience any chest pain, shortness of breath, dizziness, increased heart rate, preceding her fall from standing. She reports that while walking she “tripped,” though states that there was nothing that caused her to trip. She denied loss of consciousness. ED course was as follows: Patient had CT Head that revealed subdural hemorrhage along left temporal lobe with a small of blood in the right prepontine cistern, left basal ganglia calcification vs. hemorrhage, and right nasal bone fracture. A CTA of the head/neck was negative for large vessel occlusion. CXR revealed fracture of the 3^rd and 4^th right ribs. Right Hip XR revealed intertrochanteric R Femur Fracture. Repeat CT Head showed increase in subdural hematoma with no midline shift. ED consulted neurosurgery which recommended Levetiracetam 500mg BID until 10/19 and brain MRI/EEG which were unremarkable. Patient underwent Right Cephalomedullary Nailing for R Femur Fracture on 10/14. Patient was unable to be weaned off of supplemental oxygen. For pain control, Tramadol and Methocarbamol were being utilized, though it was discontinued at the request of the patient and the patient’s daughter who complained that the medication was increasing confusion.

Currently, patient complains that she is “feeling lousy.” She states that this started this morning and she has been feeling worse and worse. Patient states that she feels very hot. She complains that she is having difficulty breathing and has slight chest pressure that does not radiate. She reports that she feels “clammy.” She states she has never felt this way before. Admits to one episode of non-bilious, non-bloody vomiting 15 minutes ago, witnessed by the patient’s aide. Admits weakness, nausea, chest pain, shortness of breath, dyspnea. Denies chills, headache, diarrhea, constipation, palpitations, cough, abdominal pain, calf swelling.

PMH: HTN, HLD, NPH, Dementia, GERD, Atrial Fibrillation, Subdural Hematoma, Right 3^rd/4^th Rib Fracture, Right Intertrochanteric Femur Fracture

PSH: PPM (2003) for Atrial Fibrillation, Right Cephalomedullary Nailing (2019) for Right Intertrochanteric Femur Fracture

Medications:

Acetaminophen 325mg tab, take 2 PO q6h prn for pain

Atorvastatin 20mg tab, 1 tab PO qhs

Diltiazem/HCTZ CD 240mg/24h oral cap ER, take 1 cap PO qd

Donepezil 5mg Tab, 1 tab PO qam

Enoxaparin 30mg SC qd

Omeprazole 20mg Cap, 1 Cap PO qd

Allergies: NKDA

Social History:

The patient is widowed and lives in a house alone with an aide that comes 8 hours daily. She ambulates using a walker and is able to transfer on her own. The patient is a retired stenographer.

Denies current or past smoking history. Denies EtOH use. Denies illicit drug use.

Family History:

Mother, Deceased, HTN, HLD

Father, Deceased, HTN, CAD

Review of Systems:

General : Admits weakness, fatigue, loss of appetite. Denies fever, chills, night sweats, weight loss

Respiratory : Admits shortness of breath, dyspnea. Denies wheezing, hemoptysis, cyanosis, cough, paroxysmal nocturnal dyspnea

Cardiovascular : Admits chest pain. Denies palpitations, irregular heartbeat, edema, syncope, known heart murmur

Gastrointestinal : Admits nausea, vomiting. Denies change in appetite, abdominal pain, intolerance to specific foods, dysphagia, pyrosis, flatulence, eructations, diarrhea, constipation, hemorrhoids, change in stool caliber, blood in stool

Genitourinary : Denies change in frequency, urgency, hesitancy, dribbling, nocturia, polyuria, oliguria, dysuria, change in urine color, incontinence, flank pain

Peripheral Vascular : Denies intermittent claudication, coldness or trophic changes, varicose veins, peripheral edema, color change

Neurologic : Denies seizures, loss of consciousness, sensory disturbances, paresthesia, dysesthesia, hyperesthesia, ataxia, loss of strength, change in mental status, memory loss, asymmetric weakness

 

Physical Exam:

Vital Signs :

T 32.2C

BP 87/63

P 76bpm

RR 26 breaths/min

SpO2 95% 3L NC

Ht: 64in. Wt: 130 lbs. BMI: 22.0 kg/m^2

General Survey : 86yo female, A/O x2 (Person, Time). Moderate distress, patient utilizing accessory muscles for breathing, diaphoretic.

Skin : Diaphoretic, cold to the touch throughout. Nonicteric.

Chest : Symmetrical. No deformities. Labored breathing with accessory muscle use noted. No paradoxical respirations. Nontender to palpation.

Lungs : Resonant to percussion throughout. Clear to auscultation bilaterally though shallow respiratory effort. No wheezing, rhonchi, or rales.

Cardiovascular : S1 and S2 normal. Regular rate and rhythm. No S3, S4, splitting of heart sounds, murmurs, rubs.

Abdomen : Soft, non-distended. Mild tenderness to palpation over suprapubic region, otherwise non-tender to palpation throughout. No striae, caput medusa, or abdominal pulsations. BS present in all four quadrants. No masses, guarding, rebound tenderness, CVAT.

 

Assessment:

AP is an 86yo White Female with PMH HTN, HLD, NPH, Dementia, GERD, PPM for Atrial Fibrillation (2003), Subdural Hematoma, Right 3^rd/4^th Rib Fracture, Right Intertrochanteric Femur Fracture s/p Right Cephalomedullary Nailing (2019) with recent admission to Margaret Tietz Nursing and Rehabilitation Center for restorative therapies. At this time, she is complaining of fatigue, weakness, nausea, vomiting and is noted to be diaphoretic, to have hypothermia, hypotension, tachypnea with accessory muscle use, and mild tenderness to palpation over the suprapubic region concerning for Urosepsis versus ACS versus PE.

#Urosepsis versus ACS versus PE – Unstable

– Start 1L NS Bolus

– Stat CBC, CMP, Blood Cx x2, Troponin, UA, Ucx, Fingerstick Glucose

– Start IV Piperacillin/Tazobactam 3.375g q6h

– Stat EKG

– Stat CXR

– Give ASA 81 mg chewable tab, 3 tabs PO chewed (patient already received one this AM)

– Continuous monitoring of V/S

– Prepare for transfer to NYPQ ED

 

#Right Intertrochanteric Femur Fracture s/p Right Cephalomedullary Nailing (2019)Right 3^rd, 4^th Rib Fractures,  – Pain Stable

– Cont. Acetaminophen 325mg tab, take 2 PO q6h prn for pain

 

#HTN – Patient currently Hypotensive

– Hold Diltiazem/HCTZ CD 240mg/24h oral cap ER, take 1 cap PO qd

 

#HLD – Stable

– Cont. Atorvastatin 20mg tab, 1 tab PO qhs

 

#NPH, Dementia – Stable

– Cont. Donepezil 5mg Tab, 1 tab PO qam

 

#GERD – Stable

– Cont. Omeprazole 20mg Cap, 1 Cap PO qd

 

DVT Prophylaxis: Intermittent Pneumatic Compression, Enoxaparin 30mg SC qd

 

Nutrition: DASH Diet

Disposition: Patient to be prepared for immediate transfer to NYPQ ED for further work up and treatment

/s/ Daniel DeMarco, PA-S

Physician Assistant Student

Differential Diagnosis:

– SIRS/Sepsis (due to possible UTI or other infectious etiologies like PNA)

– ACS

– PE

– Expanding Hematoma in R Inguinal Region