IDENTIFICATION: May 18, 2019

PS, F, African American, 65 years old, widow, 456 369th St, Brooklyn, NY 11215, Baptist.

INFORMANT: Patient is a reliable historian.

REFERRAL SOURCE: Self.

CHIEF COMPLAINT: ‘Dizziness’ x 2-3 months.

PRESENT ILLNESS: PS is a 65-year-old female, with a PMH significant for COPD, non-malignant bladder mass s/p biopsy and urinary retention s/p bladder TURBT, who presents to the ED with complains of dizziness for the past two-three months.  Patient reports the dizziness has not increased in severity but notes she no longer feels safe walking without assistance, prompting her visit to the ED today. Patient describes her dizziness as both lightheadedness and vertigo and reports it is worsened after going from sitting to standing.  Patient denies taking any medications to alleviate her symptoms.

Patient also reports a headache described as 5/10 intensity that was gradually onset and generalized in nature.  Patient denies any recent head trauma or hearing changes, fever, chills, neck pain/stiffness, chest pain, cough, dyspnea, abdominal pain, nausea, vomiting, diarrhea, constipation, dysuria, frequency, rash or lower extremity edema.

Of note, a CT Head was completed on 1/13/19 for dizziness revealing age-appropriate unremarkable findings.  

PAST MEDICAL HISTORY

• COPD
• Non-malignant bladder mass s/p biopsy
• Urinary Retention s/p bladder TURBT

PAST SURGICAL HISTORY

• Hysterectomy – 1994
• TURBT – 3/26/2019

MEDICATIONS

• Tamulosin 0.4mg CAPS – 1 capsule PO at bedtime

ALLERGIES

• NKDA
• No food/environmental allergies

FAMILY HISTORY

• Mother, deceased, breast CA.
• Father, deceased, HTN.
• Brother, 68, alive, prostate CA.
• Sister, 59, alive and well.

SOCIAL HISTORY

• Patient is former smoker – cigarettes.  20 pack years. Quit in 2010. Patient denies any any EtOH or illicit drug use.
• Patient is a widow and lives with her sister and her sister’s family.   
• Patient retired from NYC DOE, worked as a secretary for 25 years.

REVIEW OF SYSTEMS

General: Denies recent weight loss, change in appetite, fevers and night sweats.

Skin, hair and nails: Patient denies excessive dryness or sweating, moles/rashes or pruritus.

Head: Patient reports intermittent headaches, vertigo, lightheadedness.  Denies head trauma.

Eyes: Patient denies visual disturbances, blurring, diplopia, fatigue with use of eyes, scotoma, halos, lacrimation, photophobia or pruritus. Last eye exam unknown. Patient wears glasses.

Ears: Patient denies deafness, pain, discharge, tinnitus.  Patient does not wear hearing aids.

Nose/Sinuses:  Patient denies discharge, epistaxis, obstruction.

Mouth and throat: Patient denies dry mouth, sore tongue, mouth ulcers, bleeding gums, sore throat or voice changes.  Patient does not wear dentures. Last dental exam prior to TURBT in 3/2019.

Neck:  Patient denies localized swelling/lumps or stiffness/decreased range of motion.

Breast: Patient denies lumps, nipple discharge or pain.  

Pulmonary System:  Patient denies dyspnea (SOB), dyspnea on exertion (DOE), cough, hemoptysis, cyanosis, orthopnea or paroxysmal nocturnal dyspnea (PND).

Cardiovascular System: Patient denies intermittent chest pain, HTN, palpitations, Irregular heartbeat, edema/swelling of ankles or feet, syncope or known heart murmur.

Gastrointestinal System: Patient denies abdominal pain, nausea and vomiting, change in bowel habits, constipation, changes in appetite, intolerance to specific foods, dysphagia, pyrosis, flatulence, eructations (belching, burping), diarrhea, jaundice, hemorrhoids, rectal bleeding or blood in stool.

Genitourinary System: Patient denies urinary frequency and dysuria, nocturia, urgency, oliguria, polyuria, discoloration of urine, incontinence, awakening at night to urinate or flank pain.

1. Sexual History

• • Patient is not sexually active, widow.

Nervous System: Patient reports headache, weakness and dizziness.  Patient denies seizures, loss of consciousness, sensory disturbances, numbness, paresthesias, dysesthesias, hyperesthesias, ataxia, loss of strength, change in cognition / mental status / memory.

Musculoskeletal System: Patient denies any muscle/joint pain, deformity or swelling, redness or arthritis.  

Peripheral Vascular System: Patient denies intermittent claudication, coldness or trophic changes, varicose veins, color change or peripheral edema.

Hematologic System:  Patient denies history of PE, anemia, easy bruising or bleeding, lymph node enlargement.  Patient denies blood transfusions.

Endocrine System:  Patient denies polyuria, polydipsia, polyphagia, heat or cold intolerance, goiter, excessive sweating.

Psychiatric: Patient denies depression/sadness, feelings of helplessness, feelings of hopelessness, lack of interest in usual activities, suicidal ideations, anxiety, obsessive / compulsive disorder.  

GENERAL SURVEY: 65-year-old female A/O x3.  Patient appears to be of stated age, well nourished and in no acute distress and cooperating well in the ED.

VITALS

BP: 105/52 mmHg
R: 19 BPM
P: 72 BPM
SpO2: 99% on RA
Temperature: 100.3 F
Height: 5’4’’ Weight: 162 lbs BMI: 27.9

PHYSICAL EXAM

SKIN:  Warm & dry, good turgor.  Nonicteric, no lesions, no tattoos.

HAIR: Average quantity and equal distribution.

NAILS: No clubbing, capillary refill <2 seconds throughout.

HEAD: NC/AT nontender to palpation throughout.

EYES: No conjunctival injection, bilaterally. Symmetrical OU; no evidence of strabismus, exophthalmos or ptsosis; sclera white; cornea clear. Visual fields full OU. PERRLA. EOMI without nystagmus.

EARS: Symmetrical & normal size. No evidence of lesions, masses, trauma on external ears.

NOSE: Symmetrical, no obvious masses, lesions, deformities, trauma, discharge. Nares patent bilaterally, nasal mucosa pink & well hydrated.

SINUSES: Nontender to palpation and percussion over bilateral frontal, ethmoid & maxillary sinuses.

LIPS: pink, moist, no evidence of cyanosis or lesions.

MUCOSA: pink, well hydrated. No masses; lesions noted, No evidence of leukoplakia.

PALATE: pink, well hydrated. Intact with no masses, lesions or scars.

TEETH: good dentition, no missing teeth or discoloration.

GINGIVAE: Pink, moist. No evidence of hyperplasia, masses, lesions, erythema or discharge.

TONGUE: Pink, well papillated, no masses, lesions or deviations noted. Oropharynx well hydrated, no evidence of injection, exudates, masses, lesions, foreign bodies. Tonsils present with no evidence of injection or exudates. Uvula pink, no edema, lesions.

NECK: Trachea midline, no masses, lesions, scars, pulsations noted. Supple, nontender to palpation. Full ROM, no stridor noted, 2+ carotid pulses bilaterally, no palpable adenopathy noted.

CHEST: Symmetrical, no deformities, no evidence of trauma. Respirations unlabored no paradoxical respirations or use of accessory muscles noted. Nontender to palpation.

LUNGS: Clear to auscultations & percussion bilaterally. Chest expansion symmetrical. No wheezing, rhonchi, crackle, rales noted.

HEART: RRR. S1 & S2 normal. No murmurs or gallops noted. Carotid pulses 2+ bilaterally.

ABDOMEN: No tenderness  Soft, no distention. No rigidity. BS active in all four quadrants.

RECTAL: No visible hemorrhoids or fissures.  No masses or hemorrhoids felt. Stool brown, negative for blood.

VASCULAR: The extremities are normal in color, size and temperature. Pulses are 2+ bilaterally in upper and lower extremities. No bruits noted. No clubbing, cyanosis or edema noted bilaterally (no C/C/E B/L) No stasis changes or ulcerations noted.

NEURO: Alert and oriented to person, place and time. Memory and attention intact. Receptive and expressive abilities intact. Thought coherent. No dysarthria, dysphonia or aphasia noted. Normal muscle tone, negative Romberg sign.  Coordination and gait normal. Normal finger to nose test and finger dexterity.

MUSCULOSKELETAL: No soft tissue swelling / erythema / ecchymosis / atrophy / or deformities in bilateral upper and lower extremities. Non-tender to palpation / no crepitus noted throughout. FROM of all upper and lower extremities bilaterally. No evidence of spinal deformities.

DIAGNOSTICS:

1. LABS
   1. Prothrombin Time: 14.9
   2. INR” 1.33
   3. Glucose: 137
   4. BUN: 25
   5. Creatinine: 1.49
   6. Anion gap with K: 18.5
   7. Albumin: 3.4
   8. ALT: <6
   9. AST: 10
   10. C2: 21
   11. WBC: 11
   12. RBC: 2.77
   13. Hgb: 7.2
   14. Hematocrit: 22
   15. MCV: 79.5
   16. MCH: 25.8
   17. RDW: 16
   18. Lymphocytes: 16.4
   19. ANC: 8.1
   20. All other components within normal limits
2. Urinalysis
   1. Protein: 30
   2. Blood: LARGE
   3. LEUKOCYTES: LARGE
   4. All other components within normal limits

ASSESSMENT: 65-year-old female, with a PMH significant for COPD, non-malignant bladder mass s/p biopsy and urinary retention s/p bladder TURBT, who presents to the ED with complains of dizziness presenting as symptomatic anemia in the setting of UTI and microscopic hematuria.

ED COURSE:

3:07 AM –

Labs show decreased Hgb baseline from 9-10 to 7.2.  Will complete DRE to obtain FOBT. Further questioning reveals the patient noticed darker stool color but denies any gross blood in stool.

IV Fluids NS 1 L started.  Meclizine 25mg PO given.

3:42 AM –

DRE performed, no gross blood in stool.  Stool was light brown in color. FOBT x3 sent to lab for evaluation.

3:58 AM –

Patient exhibiting orthostatic hypotension:

Lying: 115/65; Sitting: 102/55; Standing: 86/51

5:18 AM –

Type & Screen x2 were drawn.  Will initiate blood transfusion upon T&S results

6:03 AM –

Follow up with lab, T&S and FOBT still pending.  

6:25 AM –

FOBT x3 resulted as negative.

6:29 AM –

UA showing LARGE blood in sample.  Patient likely losing blood in urine given profound GU history.  Urology consult requested. MAR consult requested and obtained and will admit to medicine.

PLAN:

 

• Symptomatic Anemia

 

1. 1. Admit to Medicine for symptomatic anemia in setting of UTI and microscopic hematuria, negative FOBT
   2. Follow up with urology to evaluate source of blood loss
   3. Transfuse 1-2 units of blood once T&S completed
      1. Recheck CBC following transfusion
   4. Continue IVF hydration and Meclizine 25mg PO qd until discharge

 

• Bladder Mass s/p TURBT & Urinary Retention

 

1. 1. Urology to follow up with patient while in patient
   2. Recommend discharge with Tamulosin 0.4mg PO qd

 

• COPD

 

1. 1. Follow up with PMD and pulmonologist PRN

Differential Diagnosis

1. Symptomatic Anemia
2. UTI
3. Urinary Retention
4. Bladder Mass, subsequent encounter
5. Anemia of Chronic Disease