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Chief complaint
Mr. Hall reports severe cramping pain and swelling in his left lower leg, as well as a fall due todizziness upon standing.
Orientation
A&O x 4
History of present illness
Mr. Hall is an 80-year-old White man with a history of HTN, BPH with urinary incontinence, and arthritis who presented to the ER with complaints of left lower leg pain x 2 days and dizziness. He describes the pain as being localized to the left lower leg. He says the pain was increasingly severe yesterday and he noticed that his calf was swollen. He describes the pain as sharp, nagging and constant. He also states that this pain is different from the usual arthritis painhe gets in his hips and knees and that nothing makes the pain better or worse. He tried taking Advil for the pain at home, but it was ineffective. Upon arrival to the ER, he reports pain level 10/10 and describes it as a cramp like pain that won't ease up. Patient reports feeling dizzy for about 2 weeks, since he has had his prescription refilled. Has fallen in the past prior to the fall yesterday. However, he did not have any major injuries as a result of these falls.
Past Medical Hxof
HTN, diagnosed at age 57 Arthritis, diagnosed at age 57 Prostate enlargement with minimalurinary incontinence, diagnosed at age 69
Past surgical hx
Mr. Hall reports that he had one previous surgery for abdominal hernia at age 58.
Medication hxR
Metoprolol 25 mg, 1 tab daily for high blood pressure. Last dose this morning Finasteride (Proscar) 5 mg, 1 tab P.O. once a day last dose 1 day ago Benadryl, dosage unknown, 1 tab PRNas a sleep aid, last dose earlier this week Advil (ibuprofen) 200 mg, 1 tab PRN for leg pain last dose yesterday
Family Hx
Father died of colon cancer at age 62 Mother died of heart failure at age 78
Social History
Employment: Mr. Hall is a retired carpenter.
Marital status: He is a widower and has two adult daughters. One of them lives close by and checks on him frequently, at least every other day comes to visit and calls daily.
Tobacco use: Mr. Hall smoked cigarettes for 40 years, but quit 20 years ago.
Alcohol/Illicit Drug: Occasional alcohol use, drinks with friends and family at gatherings. Hegenerally avoids it because it give him heartburn.
He has never used drugs and denies any illicit drug use currently.
Function status and Geriatric syndrome
Mr. Hall currently lives alone. He reports being able to independently dress and feed himself, as well as bathe independently with the help of a shower bar his daughter installed for him. He experiences some urinary incontinence due to his enlarged prostate, and is able to get up from thetoilet with support (uses cane). He has some gait impairment, and occasionally uses his cane to balance while he walks as well. Mr. Hall also experiences difficulty getting out of bed and chairswithout support. He states that his sleep is usually of poor quality, with occasional insomnia and frequent waking. He says he has recently felt dizzy, especially upon standing, and that the dizziness has increased over the past two weeks. He has a prior history of falls, and reports falling twice within the last 6 months. He visited the ER in the last 3 months after one of these falls, getting a hip X-ray with no fracture found. Mr. Hall reports that his skin is thin, and that he has had unintentional weight loss of 10 lbs over the past 6 months. He also reports fatigue most days that is increased with activity, as well as that his health sometimes prevents him from engaging in social activity.
Elder Abuse
Mr. Hall does not have signs of elder abuse or mistreatment but as a fall risk he needs adequate care. Due to his history of falls, he may need someone to check on him daily and to assist him with managing his medications. His bruising appears to be caused by the fall and not by any physical harm. He says he feels safe in his home and has a good relationship with his daughters. I would recommend that his daughter schedule regular checks to make sure he is safe, or that his family look into in-home care options.
Situation: Mr. Hall is an 80-year-old White male admitted from the ER today with the diagnosis ofDVT, fall, and dizziness.
Background: Mr. Hall has a history of HTN, BPH, osteoarthritis and occasional heartburn. He was admitted through the ER at 1 PM because of a fall this morning. He was lying in his garage until his daughter found him. His treatment plans related to this issue include labs, urinalysis, intravenous fluids, pain medications and anticoagulation.
Assessment: Mr. Hall is alert and oriented x 4. He complains of pain and rates it currently as a 2/10in his left leg. He was given acetaminophen 325 mg P.O. for pain at 1 PM, and oxycodone 5 mg P.O. for pain at 2 PM, with mild relief of pain. His left calf is edematous and warm to touch. His left leg,
hip, and knee are bruised. Denies that he hit his head, no signs of active bleeding. He gets dizzywhen he stands. He has an unsteady gait and uses a cane to walk. His urine is amber, incontinent ofurine at times. Heart sounds are RRR, breath sounds are clear in all lobes. His IV site is without redness or infiltration. He was given 5 mg Warfarin once his INR lab came back. Upon review of his
