Identifying Data:
Full Name: A. K.
Address: Queens, NY
Date of Birth: 3/27/1920
Date and Time: May 4, 2021
Source of Information: Self
Reliability: Reliable
Source of Referral: Home Care aid
Chief Complaint: “I fell”
History of Present Illness:
101-year-old gentleman with PMH of DM and hypertension, was admitted to the ER on Friday, 4/30/21, after falling on his left side. He states that he does not remember experiencing dizziness or losing consciousness before falling, and does not remember tripping before falling. He did not hit his head when he fell, and states he did not experience any long-lasting pain after falling. His aid had brought him to the hospital to make sure there were no underlying conditions or injuries that went unnoticed. Upon arriving to the ER, the patient had 2 CT scans, 2 sonograms and an EKG done, but was not told the results. He was told that he had an inner-bleed, but was not told where the bleeding was. He is scheduled for an EGD endoscopy later today, to further evaluate the bleeding. He did not take any new medications after his fall. He states that he had not experienced a fall like this in the past, where he could not remember how he fell. However, the patient admits to a fall in 2019, where he had broken his hip and fractured his right arm. Denies any bruising, swelling, new body pains, fever, chills, or night sweats.
Past Medical History
Diabetes Mellitus, controlled
Hypertension, controlled
Blepharitis
Macular degeneration of the right eye
Basal cell carcinoma of the left lower lid, resolved
Immunizations- Up to date; flu vaccine yearly
Past Surgical History
Hip surgery, 2019
Surgery on ribs, legs, and clavicles; 1968
Prior Hospitalization
Broken hip, 2019
Car accident, 1968
Medications
Januvia 200 mg daily
Metoprolol 25 mg, half in the morning and half in the evening
Aspirin 81 mg, daily
Calcium
Vitamin C
Fish Oil
Allergies
Peanuts
Penicillin
Family History
Mother- deceased
Father- deceased
Wife- deceased
Brother- deceased, hx of colon cancer
Sister- deceased, hx of lung cancer
Son- 25, hx of DM, deceased
Son- 67, alive and well
Social History
A.K. is a single male, living with his home care aid. He previously worked as a professor, and retired 3 years ago.
Habits- He drinks 1 glass of red wine for dinner. He has never smoked tobacco. He drinks 1 cup of coffee in the morning.
Travel- no recent travel
Diet- He has a simple diet, consisting of chicken, rice, and vegetables
Exercise- He is unable to exercise, as he has difficulty walking
Safety measures- Admits to wearing a seat belt
Sexual Hx- Heterosexual, he is not sexually active
Review of Systems
General- Admits to weight loss over the past few years due to anxiety. Admits to difficulty walking, since 2019 when he broke his hip. Denies fever, chills, or night sweats.
Skin, hair, nails- Denies changes in texture, excessive dryness or sweating, discolorations, pigmentations, moles/ rashes, pruritus or changes in hair distribution
Head- Denies headache, vertigo, or head trauma
Eyes- Admits to hx of blepharitis and basal cell carcinoma in the left lower lid, which has resolved.
Ear- Denies deafness, pain, discharge, tinnitus, or use of hearing aids
Nose/ sinus- Admits to anosmia. Denies discharge, obstruction, or epistaxis
Mouth/ throat- Admits to increased production of sputum, and experiences some difficulty swallowing. Denies bleeding gums, sore tongue, sore throat, mouth ulcers, voice changes or dentures.
Neck- Denies localized swelling/ lumps or stiffness/ decreased range of motion
Pulmonary system- Admits to productive cough. Denies dyspnea on exertion, wheezing or hemoptysis.
Cardiovascular system- Denies history of hypertension, chest pain, irregular heartbeat, edema/ swelling of ankles or feet
Gastrointestinal system- Admits to constipation. Denies change in appetite, nausea, vomiting, pyrosis, unusual flatulence or eructation, abdominal pain, diarrhea, jaundice, hemorrhoids, constipation
Genitourinary system- Admits to frequency and urgency. Denies nocturia, oliguria, polyuria, dysuria, or incontinence
Nervous- Denies seizures, headache, loss of consciousness, sensory disturbances, ataxia, loss of strength, change in cognition/ mental status/ memory, or weakness
Musculoskeletal system- Admits to hip pain, and cannot walk without his walker, and is unable to climb stairs on his own. Denies swelling, redness or arthritis.
Peripheral vascular system- Denies intermittent claudication, coldness or trophic changes, varicose veins, peripheral edema or color changes
Hematological system- Denies anemia, lymph node enlargement, blood transfusions, or history of DVT
Physical
General: Thin male, neatly groomed, looks younger than his stated age of 101
Vital signs:
BP: seated, L 124/70
R: 24/ min unlabored
P: 80, regular
T: 98.6 degrees F (oral)
O2 sat: 97% room air
Height: 68 in
Weight: 135 lbs.
Skin: warm, moist, good turgor. Signs of purpura on right forearm. Non-icteric, no scars, tattoos.
Hair: balding, thin hair
Nails: no clubbing, capillary refill < 2 seconds in upper and lower extremities
Head: normocephalic, atraumatic, non-tender to palpation throughout
Ear: Symmetrical and appropriate in size. No lesions/ masses/ trauma on external ears. No discharge/ foreign bodies in external auditory canals AU. TM is pearly white/ intact with light reflex in good position AU. Auditory acuity intact to whispered voice AU. Weber midline/ Rinne reveals AC> BC AU.
Nose: Symmetrical/ no masses/ lesions/ deformities/ trauma/ discharge. Nares patent bilaterally/ nasal mucosa pink and well hydrated. No discharge noted on anterior rhinoscopy. Septum midline without lesions/ deformities/ injection/ perforation. No foreign bodies.
Sinus: Non tender to palpation and percussion over bilateral frontal, ethmoid and maxillary sinuses
Eyes: Symmetrical OU. NO strabismus, exophthalmos or ptosis. Sclera white, cornea clear, conjunctiva pink
Visual acuity corrected- 20/20 OD
Visual fields full OU. PERRLA. EOMs intact with no nystagmus
Fundoscopy- Red reflex intact OU. Cup to disk ration < 0.5 OU. No AV nicking, hemorrhages, exudates or neovascularization OU.
Lips: pink, moist; no cyanosis or lesions
Mucosa: pink; well-hydrated. No masses; lesions noted. Non-tender to palpation. No leukoplakia.
Sinus: Non tender to palpation and percussion over bilateral frontal, ethmoid and maxillary sinuses
Palate: pink; well hydrated. No lesions, masses, scars
Teeth- good dentition, no obvious dental caries noted
Gingivae: pink, moist. No hyperplasia, masses, lesions or deviation.
Oropharynx: well hydrated; no injection, exudate, masses, lesions, foreign bodies. Tonsils present with no injection or exudate. Uvula pink, no edema, lesions
Neck: Trachea midline. No masses, lesions, scars, pulsations noted. Non-tender to palpation.
Thyroid: Non-tender, no palpable masses, no thyromegaly
Chest: Symmetrical, no deformities, no trauma. Respirations unlabored/ no paradoxical respirations or use of accessory muscles noted. LAT to AP diameter 2:1. Non-tender to palpation throughout
Lungs: Clear to auscultation and percussion bilaterally. Chest expansion and diaphragmatic excursion symmetrical. Tactile fremitus symmetric throughout. No adventitious sounds.
Heart: JVP is 2.5 cm above the sternal angle with the head of the bed at 30 degrees. Carotid pulses are 2+ bilaterally without. Bruits. Regular rate and rhythm. S1 and S2 are distinct with no murmurs. No splitting of S2 or friction rubs appreciated
Abdomen- abdomen flat and symmetric with no scars, striae or pulsations noted. Bowel sounds normoactive in all four quadrants with no aortic/ renal/ iliac or femoral bruits. Non-tender to palpation and tympanic throughout, no guarding or rebound noted.
