Identifying Data

Date: September 19, 2019

Sex: Male

Age: 92 years old

Location: NYPQ

Source of information: self

 

Chief complaint: Found on floor in AM by home health aide

 

HPI

92-year-old male with PMHx of dementia, HLD and BPH presented to ED status post unwitnessed fall. Pt does not recall how or why he fell. Pt was found by home health aide on the floor in the morning. Pt next of kin Margaret (niece) states that he ambulates alone at home and lives alone except for a visiting home health aide that comes for several hours each day. All imaging (CT head, spine, XR pelvis and hip) in ED came back negative for fractures or bleeds. Pt was admitted to medicine for further evaluation by orthopedics. F/u CT pelvis showered left nondisplaced greater trochanter fracture. As per Dr. Sloane (pts PCP) pt has worsening dementia and is a candidate for nursing home and should be discussed with niece. Pt denies pain, chest pain, SOB, HA, N/V/D, urinary symptoms but is an unreliable historian.

 

Past medical history:

• Dementia
• HLD
• BPH

Past hospitalizations: non-contributory

Surgical history: denies

Immunizations: Up to date

Medications:

• Aspirin 81mg
• Atorvastatin 20mg QD
• Tamsulosin 0.4 mg daily

Family history: non-contributory

 

Social history:

92-year-old male, lives alone with niece next door. Pt has visiting nurse for several hours each day.

Habits: Pt denies drinking alcohol, smoking cigarettes or illicit drug use

Diet: pt eats well balanced diet

Exercise: pt has sedentary lifestyle

Sexual history: not sexually active

 

Review of Systems (pt in unreliable and denies any physical complaints)

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

Skin, hair, and nails: Denies changes in texture, excessive dryness or sweating, discolorations, pigmentations, moles/rashes 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 deafness, pain, discharge, tinnitus, and hearing aids

Nose/sinuses: denies discharge, epistaxis, and obstruction

Mouth and Throat: Denies sore throat, SOB, bleeding gums, sore tongue, mouth ulcers, voice changes, or dentures.

Neck: denies localized swelling/lumps, stiffness/decreased range of motion

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

Cardiovascular: Denies HTN, edema, irregular heartbeat, CP, palpitations, and syncope.

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

Nervous: Denies headaches seizures, loss of consciousness, sensory disturbances, ataxia, loss of strength, change in cognition / mental status / memory, or weakness.

Musculoskeletal system: Denies muscle/joint pain, swelling of legs, arthritis, deformity, redness.

Peripheral vascular system: 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, OCD or ever seeing a mental health professional

 

Physical Exam:

General: Slender male, in no acute distress, A/O x2 (person and place).

 

Vital signs: BP 120/68, P 83 regular, O2 97% room air, T 37.0 C, RR 17 BPM

 

Skin: warm & moist, good turgor.

Hair: pt displays male pattern balding.
Nails: no clubbing, capillary refill <2 seconds throughout.
Head: normocephalic, atraumatic, non-tender to palpation throughout.

Eyes: symmetrical OU; no evidence of strabismus, exophthalmos or ptosis; sclera white; conjunctiva & cornea clear

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.

 

Mouth: mucosa pink, moist, no evidence of masses, edema or lesions. Injected oropharynx, no evidence of exudate, angioedema or inflammation.

 

Neck: Trachea midline. No masses; lesions; scars; pulsations noted. Supple; non-tender to palpation. FROM. No JVP

Heart: RRR, S1 and S2 are present, no gallops, rubs or murmurs

 

Chest: symmetrical, no deformities, no evidence of trauma. Non-tender to palpation.

Lungs: lungs clear to auscultation, no wheezing, rales or rhonchi. Chest expansion symmetrical.

 

Abdomen: Symmetrical, no evidence of striae, caput medusae or abnormal pulsations, BS present in all four quadrants. Non-tender to light/deep palpation. No evidence of organomegaly. No masses noted. No evidence of guarding or rebound tenderness. No CVAT noted bilaterally.

 

Extremities: Mild left hip pain upon passive ROM, Full range of motion in other joints, no edema, erythema, or deformities. Pulses intact throughout. No clubbing or cyanosis. Capillary refill <2 seconds throughout.

 

Neurological: A/O to person and place. Does not recall falling or breaking hip.

 

Labs:

Chemistry:

• BUN 28

LFT: WNL

CBC: WNL

UA: negative

 

Imaging:

• CT head, CT spine, XR Pelvis, XR hip WNL, no fractures or acute bleed
• XR chest: negative for PNA
• CT pelvis: left nondisplaced greater trochanteric fracture without intertrochanteric extension

EKG: NSR

 

Assessment: 92-year-old male with PMHx of dementia, HLD and BPH presented to ED status post unwitnessed fall. On PE pt displayed pain in passive ROM of left hip. CT pelvis revealed a left nondisplaced greater trochanter fracture.

 

Plan:

 

• Left nondisplaced greater trochanter fracture
  • Ortho consult: non-surgical, weight bearing as tolerated with walker or cane. F/u with ortho outpatient in 2 weeks.
  • No leukocytosis, afebrile, UA negative
  • CT head, CT spine WNL
• Dementia
  • Social work: Pt ready for discharge, awaiting meeting with niece to plan for safe discharge. Unsafe for pt to return to live alone with only part time assistance
• HLD
  • Continue with home dose of atorvastatin 20mg daily
  • Low fat cardiac diet
• BPH
  • Continue with home dose of Tamsulosin