Identifying data

Name: W.T.

Sex: male

Race: African American

Location: V.A. St. Alban’s

Source of information: self

 

Chief complaint: “I fell from my bed” x5 hours ago

 

HPI

78 y/o male, PMHx of prostate cancer s/p external beam radiation therapy and brachytherapy, spinal stenosis, sleep apnea, HTN, HLD, Hep C genotype 1 (IVDU), h/o cocaine/heroin use and alcoholism. Pt presented s/p fall. As per pt, he was getting up from bed in order to go to bathroom, when he felt dizzy, tries to sit back down and fell to the floor. Dizziness resolved spontaneously within seconds of the fall. Fall was unwitnessed. Pt states that he did not hit his head but landed on his left shoulder.  pt was able to ambulate to chair after fall without assistance. Pt admits to dull non- radiating 3/10 pain to his left shoulder and right lateral aspect of neck. Pain is aggravation by shoulder/neck movement. Pt admits to decreased ROM in left shoulder secondary to pain. Cervical ROM was previously reduced secondary to laminectomy, but pt states ROM has worsened and the pain is new. Pt has been given Tylenol for the pain, which he states, “helped a little.” Pt denies, swelling, headache, current dizziness, chest pain, nausea, vomiting, tinnitus, bleeding.

 

Past medical history:

• Prostate cancer- currently on radiation therapy
• Spinal stenosis, s/p laminectomy and spinal fusion (2/11/19)- asymptomatic
• HTN- well controlled
• HLD- well controlled
• Sleep apnea- CPAP dependent
• Hepatitis C- resolved
• Substance use disorder- in remission

Past surgical history

• Laminectomy and spinal fusion- 2/11/19- no complications

Past hospitalizations: as related to laminectomy

Immunizations: up to date

Screenings: colorectal screening 2011- results unremarkable

Allergies: denies environmental, food and drug allergies

 

Medications:

ASA 81mg PO QD

Acetaminophen 1000mg Q12H

Amlodipine 5mg PO QD
Atorvastatin calcium 80mg PO QD

 

Family history

Mother: deceased age 76- HTN, HLD, DM

Father: deceased age 81- CHF

 

Social History:

W.T.  is a male veteran who resides at St. Alban’s long-term care facility. Pt is retired but previously worked as a mechanic. Pt served in Vietnam

Habits: pt admits to history of IVDU (heroin), cocaine use, ETOH addiction and cigarette use with 10 pack year history. Patient last used illicit drugs 15 years ago, last drank alcohol 2 years ago upon admission, pt currently smokes 3-5 cigarettes/day.

Travel: denies recent travel

Diet: pt eats diet provided by facility

Exercise: Pt participates in physical therapy and walks throughout the unit. Pt is reliant on walker to ambulate

Sleep: 6-7 hours/night

Sexual history: patient is not sexually active, denies history of STIs

 

Review of Systems:

General: Denies fatigue, weakness, fever, chills, night sweats, loss of appetite, recent weight loss or gain.

Skin, hair, and nails: Denies changes in texture, excessive dryness or sweating, discolorations, pigmentations, moles/rashes, pruritis and changes in hair distribution.

Head: denies headache, vertigo, head trauma, unconsciousness, coma, fracture.

Eyes: denies visual disturbances, fatigue, lacrimation, photophobia or pruritis.

Ears: Denies hearing loss, pain, discharge, tinnitus

Nose/sinuses: denies discharge, epistaxis, and obstruction

Mouth and throat: Denies bleeding gums, sore tongue, sore throat, mouth ulcers, voice changes, difficulty chewing and swallowing or dentures.

Neck: Admits to mild decreased range of motion related laminectomy and spinal fusion, which has worsened since fall, and pain on right lateral neck secondary to fall. Denies localized swelling/lumps

Pulmonary System: Denies dyspnea, orthopnea, SOB, PND, cough, wheezing, hemoptysis and cyanosis.

Cardiovascular: Denies chest pain, palpitations, irregular heartbeat, and syncope.

Gastrointestinal system: Denies change in appetite, intolerance to foods, nausea, vomiting, hemorrhoids, dysphagia, pyrosis, flatulence, eructation, abdominal pain, diarrhea, jaundice, change in bowel habits, constipation, rectal bleeding, blood in stool, pain in flank

Nervous: Admits to dizziness prior to fall. Denies seizures, headache, loss of consciousness, sensory disturbances, ataxia, loss of strength, change in cognition / mental status / memory, or weakness.

Musculoskeletal system: admits to left shoulder pain and decreased ROM and right neck pain and decreased ROM. Denies deformity or swelling, redness or arthritis

Peripheral vascular: denies varicose veins, peripheral edema, intermittent claudication, coldness or trophic changes, or color change

Hematological system: Denies anemia, easy bruising or bleeding, lymph node enlargement, blood transfusions, or history of DVT/PE.

Endocrine system:  Denies polyuria, polydipsia, polyphagia, heat or cold intolerance, excessive sweating, hirsutism, or goiter.

Psychiatric: Denies depression/sadness, anxiety

 

Physical

General: Obese male, appears in mild distress, neatly groomed, appears stated age, A/O x3

Vitals: BP 130/82, T 97.9 F, Pulse 71 BPM, O2 97% room air, RR 18 unlabored, Height: 71 inches, weight 228 lb. BMI: 33.7

Orthostatic BP: Supine: 117/68, sitting: 122/70, standing 124/170

 

Skin: Good turgor. Noncitric, non-diaphoretic, no lesions noted, tattoos. Vertical 5-inch scar from laminectomy on posterior cervical spine, well healed, skin intact, no signs of erythema or infection

Hair: pt displays androgenic hair loss.
Nails: no clubbing, capillary refill <2 seconds in upper and lower extremities

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

Eyes: symmetrical OU; no evidence of strabismus, exophthalmos or ptosis; sclera white; conjunctiva & cornea clear.
Visual acuity (corrected – 20/25 OU).
Visual fields full OU. PERRL, EOMs full with no nystagmus.

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

Nose: Symmetrical, no obvious masses/lesions/deformities/trauma/discharge. Nares patent bilaterally/Nasal mucosa pink & well hydrated. No discharge noted on anterior rhinoscopy. Septum midline without lesions/deformities/injection/perforation. No evidence of foreign bodies.

Oropharynx: Mucosa pink, moist, no signs of cyanosis, no masses or lesions throughout. No signs of gingival hyperplasia, tongue well papillated, no signs of deviation, oropharynx injected, tonsils present without exudate, uvula midline, no lesions or edema. Gag reflex present.

 

Neck: cervical spine displays limited ROM on active movement, moderately tender to palpation along right lateral aspect of neck. Trachea midline. No masses; lesions. Supple; no stridor noted. 2+ Carotid pulses, no thrills or bruits noted bilaterally, no palpable adenopathy noted. Thyroid nontender, no palpable masses, thyromegaly or bruits notes.

Heart: RRR. S1 and S2 present, No S3, S4, splitting of heart sounds, or murmurs present.

Chest/lungs: symmetrical, no deformities, no evidence of trauma. Respirations unlabored/ o paradoxical respirations or use of accessory muscles notes. Lat to AP diameter 2:1. Non-tender to palpation, lungs clear to auscultation throughout. No rales, crackles, wheezing. Chest expansion and diaphragmatic excursion symmetrical. Tactile fremitus intact throughout.

 

Abdomen: protuberant, symmetrical, no evidence of scars, striae, caput medusae or abnormal pulsations, BS present in all four quadrants. Non-tender to percussion or to light/deep palpation. Liver and spleen non-palpable. No masses noted. No evidence of guarding or rebound tenderness. No CVAT noted bilaterally.

 

Extremities: 2+ pulses bilaterally lower and upper extremities. Free ROM of all joints except for left AC joint. Left shoulder displays limited ROM secondary to pain. Overlying skin intact, 2-inch circular ecchymosis over AC joint and is tender to palpation. No signs of edema on lower or upper extremities.

 

Neurological: A/Ox3, Cranial nerves grossly intact, reflexes 2+ throughout, strength 4/5 throughout. Pt sensitive to sharp, dull and light touch. Pt dependent on walker, displays decreased walking velocity. No shuffling or pathologic gait noted.

 

MMSE: 28/30

• Orientation to time: 5/5
• Orientation to place: 5/5
• Word recognition 3/3
• Spelling W-O-R-L-D backwards: 5/5
• Word recall: 2/3
• Object recognition: 2/2
• Phrase repetition: 1/1
• Obeys 3 step command: 3/3
• Obeys written command: 1/1
• Writes a sentence: 1/1
• Copy a design: 0/1

 

Assessment: 78 y/o male, PMHx of prostate cancer s/p external beam radiation therapy and brachytherapy, spinal stenosis, obstructive sleep apnea, HTN, HLD, Hep C genotype 1 (IVDU), h/o cocaine/heroin use and alcoholism, and smoking cigarettes. Pt presented s/p fall. On physical exam right lateral aspect of neck tender to palpation with moderately decreased ROM. Area of ecchymosis over left shoulder with limited ROM secondary to pain. Presentation consistent with neck/shoulder contusion, r/o fracture.

 

1. Neck/shoulder contusion, r/o fracture
   1. Vital signs stable
   2. Neurological exam within normal limits
   3. Finger stick 130
2. Prostate cancer s/p EBRT and brachytherapy
   1. Stable, asymptomatic
   2. PSA 0.01 on 06/06/19
3. HTN
   1. Well controlled on current medications
4. HLD
   1. Well controlled on current medications
5. History of substance use
   1. Stable, in remission
6. Hep C
   1. S/p 8-week treatment Harvoni in 2017
7. Spinal stenosis s/p laminectomy and spinal fusion
   1. Scar well healed, no signs of infection
8. Obstructive sleep apnea
   1. Stable with CPAP
9. Obesity
   1. Not well controlled
   2. Current BMI: 33.7
10. Cigarette smoking
    1. Counseling provided, pt not interesting in smoking cessation

 

Plan:

1. Neck/shoulder contusion, r/o fracture.
   1. Transfer to Queens hospital ED for imaging studies of head, neck and shoulder
   2. Place in cervical collar for transfer
2. Prostate cancer s/p EBRT and brachytherapy
   1. Continue with radiation therapy, next appointment on 08/08/19
3. HTN
   1. Continue with low salt diet and current medications
4. History of substance use
   1. Continue regular appointments with psychologist
5. HLD
   1. Continue with low carb diet
6. Spinal stenosis s/p laminectomy and spinal fusion
   1. Continue with physical therapy
   2. f/u neurosurgery appt. and CT on 08/20/19
7. Obstructive sleep apnea
   1. Continue with CPAP night
   2. Continue with weight loss regimen
8. Obesity
   1. Continue with low fat, low carb diet
   2. Continue with Biweekly weights
   3. Continue with physical therapy
   4. Encourage exercise with walker
   5. Nutrition consult to discuss importance of weight loss with patient
9. Inpatient quality of life
   1. Chaplain services weekly
   2. Encourage going outdoors when weather permits
10. Preventative care
    1. Quantiferon negative on 2/14/18
    2. Colonoscopy screening no longer recommended as per USPTF guidelines
    3. DVT prophylaxis: Pt ambulates regularly
11. There is no plan for discharge at this time