IDENTIFICATION: October 16, 2019
LC, M, Asian American, 88 years old, married, 1827 Laurel Ave, New York, NY 12124, Protestant.

INFORMANT: Patient herself is a reliable historian, accompanied by son who serves as a reliable historian as well.

REFERRAL SOURCE: Self / Son

CHIEF COMPLAINT: ‘s/p Right Hip Fracture / CM fixation’ x one week

PRESENT ILLNESS: 88 year old male with PMH significant for DM2, CAD, HTN, HLD, PVD, Gout, CKD, CVA, Anemia and CVA with right-sided weakness (2015) brought in by ambulance to NYP LMH complaining of right sided hip pain s/p mechanical fall.  Patient states he had difficulty ambulating immediately prior to arrival while trying to walk and make coffee, when he tripped on his slippers, fell and landed on his right side. Denies LOC or head strike but notes he was unable to get up off the ground for four hours until his son arrived and helped him to stand as his wife was volunteering.  Patient / son notes he was unable to bear weight upon standing. Patient denied any dizziness, chest pain, palpitations prior to falling.  

Of note, patient reports a previous fall two months prior, requiring assistance off the ground, denies seeking medical attention.  At baseline, patient lives with wife and ambulates with a cane, is able to walk one block before stopping, lives in a second floor walk up and admits to feeling tired climbing the stairs each time.  Denies chest pain or pressure, shortness of breath or difficulty breathing, nausea, vomiting, diarrhea, constipation, headache.

In ED, patient exhibited right hip pain, which was relieved with Morphine 2mg IV.  Patient able to wiggle toes but sensation is decreased when compared with the left leg. Pelvis X-Ray in ED revealed an acute mildly displaced right intertrochanteric fracture with mild medial displacement of the lesser trochanteric fracture fragment and mild coxa varus angulation.  CT Head noted no acute intracranial process. Bilateral lower extremity venous duplex completed without any sonographic evidence or lower extremity DVT. 

Patient admitted to orthopedics service for repair.  Orthopedics placed CM nail on 10/12 without complications.  Patient’s pain controlled with Tylenol and Oxycodone as needed.  Patient continued his multi-vitamin regiment and home meds and was started on a 21 day course of DVT prophylaxis on 10/13.  Patient was monitored for bleeding given Plavix prescription and ulcer precautions were taken. Patient discharged by orthopedics, scheduled for outpatient ortho follow up and medically cleared for transfer to subacute rehabilitation at Gouverneur.  

On admission to Gouverneur Skilled Nursing Facility, patient, accompanied by son, resting comfortably in his room, without complaints of pain in right hip. Patient denies headache, dizziness, shortness of breath, palpitations, abdominal pain, nausea, vomiting, diarrhea, constipation. Patient and son discuss the use of physical therapy while inpatient at Gouverneur and note patient will be staying at son’s home, where he will continue PT, upon discharge for ease of maneuvering and elevator access.

PAST MEDICAL HISTORY

• DM2
• CAD
• HTN
• HLD
• PVD
• Gout
• CKD
• CVA
• Anemia 
• CVA with right-sided weakness (2015) 

PAST SURGICAL HISTORY

• Right CM Nail Placement s/p Right Hip Fracture (10/12/19)

MEDICATIONS

• Enoxaparin 30mg IM qday (through 11/2/19)
• Ferrous Sulfate 325mg 1 tab PO TID
• Cyanocobalamin 1000mcg PO qday
• Oxycodone 5mg PO q6h PRN
• Acetaminophen 325mf, 3 tabs PO q8h PRN
• Senna 17.2 PO qhs PRN
• Nephlex 1 tablet PO qday
• Plavix 75mg PO qday
• Coreg 25mg PO BID
• Simvastatin 40mg PO qhs
• Acarbose 50mg PO TID
• Tradjenta 5mg PO qday
• Glipizide 5mg PO TID
• Nifedipine 30mg PO qday

ALLERGIES

• NKDA
• No food/environmental allergies

FAMILY HISTORY

• Noncontributory, no history of breast, cervical, ovarian, uterine or colon cancer. No history of degenerative bone disease or arthritis. No history of CVA or CAD.

SOCIAL HISTORY

• Patient reports denies EtOH or illicit drug use.  Former smoker x5 years as a teenager. Lives with wife in a second floor walk up, no home health aid.  Patient uses an assistive device for ambulation.

REVIEW OF SYSTEMS
General:  Reports right sided weakness s/p CVA (2015).  Denies fatigue, 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 denies intermittent headaches, vertigo, light-headedness or 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 does not wear 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 jaw tightness, dry mouth, sore tongue, mouth ulcers, bleeding gums, sore throat or voice changes.
Neck:  Patient denies localized swelling/lumps or stiffness/decreased range of motion.
Pulmonary System:  Patient denies dyspnea on exertion (DOE), dyspnea (SOB), cough, hemoptysis, cyanosis, orthopnea or paroxysmal nocturnal dyspnea (PND).
Cardiovascular System: Reports HTN.  Patient denies chest pain, palpitations, irregular heartbeat, edema/swelling of ankles or feet, syncope or known heart murmur.
Gastrointestinal System:  Patient denies bloody diarrhea and abdominal pain / discomfort, nausea, vomiting, changes in appetite, intolerance to specific foods, dysphagia, pyrosis, flatulence, eructations (belching, burping), jaundice or  hemorrhoids.
Genitourinary System:  Patient denies urinary frequency and hematuria, dysuria, urinary urgency, discoloration or urine, nocturia, oliguria, polyuria, incontinence, awakening at night to urinate or flank pain.

1. Sexual History 

• • Patient is in a monogamous relationship with his wife.  Limited sexual activity.

Nervous System: Patient denies headache, seizures, loss of consciousness, sensory disturbances, numbness, parethesias, dysesthesias, hyperesthesias, ataxia, loss of strength, change in cognition / mental status.
Musculoskeletal System: Reports right hip pain s/p CM Nail placement.  Denies neck pain, swelling and bruising or any history of arthritis.
Peripheral Vascular System: Patient denies peripheral edema, intermittent claudication, coldness or trophic changes, varicose veins or color change.
Hematologic System:  Patient denies history of PE, easy bruising or bleeding, lymph node enlargement.  Patient denies blood transfusions.
Endocrine System:  Reports DM2. Patient denies polyuria, polydipsia, polyphagia, heat or cold intolerance, goiter, excessive sweating.
Psychiatric: Patient denies depression, anxiety, depression/sadness, feelings of helplessness, feelings of hopelessness, lack of interest in usual activities, suicidal ideation, anxiety, obsessive / compulsive disorder.  

GENERAL SURVEY: 88-year-old male A/O x3, appears to be of stated age, in no acute distress and cooperating well with son at bedside.

VITALS

BP: 130/70 mmHg (supine left arm)
R: 18 BPM
P: 75 BPM
SpO2: 97% on RA
Temperature: 97.5 F
Weight: 110 lbs Height: 5’4’’ BMI: 18.9

PHYSICAL EXAM
SKIN:  Well-healing scar noted to right lateral upper extremity, no erythema, edema or signs of infection.  Aquacell dressing in place, clean and dry. Warm & dry, good turgor. Nonicteric, no lesions, no tattoos.
HAIR: Good quantity and equal distribution.
NAILS: No clubbing, capillary refill <2 seconds throughout.
HEAD: NC/AT nontender to palpation throughout.
EYES: PERRLA. No conjunctival injection, bilaterally, cornea clear. EOMI bilaterally, no discharge.
EARS: Symmetrical & normal size. No evidence of lesions, masses, trauma on external ears. No discharge or foreign bodies in external auditory canals AU. TMs 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 or perforation. No evidence of foreign body.
LIPS: pink, chapped, 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.
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, tonsilith noted on left tonsil. Uvula pink, no edema, lesions.
NECK: No JVD, thyroid not palpable, no crepitus.
LUNGS: Good air entry, bilaterally decreased breath sounds at bases, normal respiratory effort  without any wheezing, rhonci, crackles, rales.
HEART: Irregularly irregular rate and rhythm. S1 & S2 normal. No murmurs or gallops noted.  Carotid pulses 2+ bilaterally.
ABDOMEN:  Soft, non-tender, BS active in all four quadrants. No abdominal tenderness. No rebound, guarding or peritoneal signs.  No CVA tenderness.
GENITOURINARY: Deferred
VASCULAR: The extremities are normal in color, size and temperature. Pulses are 2+ bilaterally. No clubbing or cyanosis noted bilaterally (no C/C B/L).
NEURO/PSYCH: Alert and oriented to person, place and time. Appropriate affect.
MUSCULOSKELETAL:  No erythema, ecchymosis, edema or acute abnormality noted, FROM, sensation intact bilaterally with decreased strength on right upper and lower extremities compared to left.

DIAGNOSTICS:
IMAGING –
Head CT (10/10):
No acute intracranial process
XRay Right Hip (10/10):
Acute mildly displaced right intertrochanteric fracture with mild medial displacement of the lesser trochanteric fracture fragment and mild coxa varus angulation.
Chest XRay (10/10):
No evidence of acute cardiopulmonary disease
CT A/P (10/19):
No acute intra-abdominal or pelvic pathology identified.  No CT evidence of colitis.
Lower Extremity Venous Duplex (10/11):
No sonographic evidence of right or left lower extremity DVT
XRay Right Hip (10/13):
Hardware in place

LABS –

• Glucose: 143
• Sodium: 141
• Potassium: 3.7
• Chloride: 111
• CO2: 19
• BUN: 24
• Creat: 1.1
• Ca2+: 8.1
• Anion Gap: 11
• WBC: 11
• Hgb: 9.2
• HCt: 28.3
• Platelets: 202
• Iron: 20ug/dL
• Iron Saturation: 13.8%
• TIBC: 145
• Ferritin 572.91 ng/mL
• Vitamin B12: 371
• Vitamin D25: < 13

ASSESSMENT:
88-year-old male with PMH significant for DM2, CAD, HTN, HLD, PVD, Gout, CKD, CVA, Anemia and CVA with right-sided weakness (2015) presented to NYP LMH ED s/p mechanical fall (10/10) and found to have an acute mildly displaced right intertrochanteric fracture requiring orthopedic CM nail placement (10/12) and subacute rehabilitation care and management at discharge from NYP LMH (10/16).

PLAN:

• Right Intertrochanteric Fracture – stable s/p CM Nail Placement, continuing PT in SAR:

1. 1. 1. Follow up with Dr. Darren Friedman on 11/13/2019 at 10AM 
      2. Pain management 
         1. Tylenol 325mg, 3 tabs PO q8h PRN
         2. Oxycodone 5mg PO q6h PRN (for pain 7-10)
      3. Continue Lovenox 30mg Injectable qday through 11/2 for DVT Prophylaxis
      4. Continue Physical Therapy 3-5x a week with patient and family education and gait training
      5. Prepare for discharge, coordinate with social worker for discharge to son’s home ensuring all equipment is available at home

• DM2 – stable, last BG 178:

1. 1. 1. Monitor blood glucose levels BID
      2. Continue Acarbose 50mg PO TID
      3. Continue Tradjenta 5mg PO qday
      4. Continue Glipizide 5mg PO TID

• HTN – stable, well managed with medications:

1. 1. 1. Monitor / Trend BP
      2. Continue Nifedipine 30mg PO qday
      3. Continue Coreg 25mg PO BID

• HLD – stable, no complaints, well-managed with medications:

1. 1. 1. Continue Simvastatin 40mg PO qhs

• CKD – stable, followed by private nephrologist, managed by medications:

1. 1. 1. Continue Nephlex 1 tab PO qday

• CVA / CAD / PVD – no changes, CT head negative, managed by medications:

1. 1. 1. Continue Plavix 75mg PO qday

• Iron Deficiency Anemia – borderline H/H, increase frequency:

1. 1. 1. Continue Ferrous Sulfate 325mg PO TID (increased from BID)

• Constipation – postoperatively:

1. 1. 1. Continue Senna 17.2mg PO qday PRN

• Vitamin Coverage – managed well with medications:

1. 1. 1. Continue Cyanocobalamin 1000mcg PO qday 

• Gout 

1. 1. Monitor for signs of a flare and follow up as needed 
   2. Not currently on medication