History

CC:

New Admission H&P

HPI:

This is a 66 year old female with a past medical history of osteoporosis, overactive bladder and MDD and past surgical history of gastric bypass in 2017 admitted to Bellevue Hospital on 11/7 after a Murphy bed collapsed on her at home. Pt says that she was reaching inside the bed to get a pillow out and that the bed fell on top of her. She was partially pinned under the bed, however one corner of it got stuck on something and therefore she was not fully crushed under. There were no witnesses. Pt admits to hitting her head and loss of consciousness at the time. When she regained consciousness she tried to get up on her own for about an hour and a half. She could not get up due to pain and called a friend who came and called EMS. At Bellevue hospital, pt got CT scans of her head, neck and spine which located an acute L3 vertebral fracture with mild spinal stenosis. Trauma surgery was consulted and the decision was made not to operate on the pt at this time. Pt was admitted to their service for PT, OT and pain control. She was doing well with the pain regimen of Oxycodone 10 mg Q6H, Methocarbamol 500 mg Q6H and Gabapentin 600 mg TID. On her last day in the hospital, pt says she was able to sit up in bed, get out of bed and get back in bed on her own. 

Today pt was seen and evaluated at bedside, A&O x4, in obvious discomfort. Pt says that since she got here last night she has not received any pain medications, and thus feels that she regressed in her recovery. The pain she feels is located in her lower back and sometimes radiates down bilateral legs. It is a sharp pain that is rated 5/10 at baseline, but with movement it is exacerbated to 10/10 in severity. Pt states that today with no pain control, she could barely walk to the bathroom even with help, which is something that she was able to do yesterday with proper pain control. Pt is also concerned because she has not yet received any of her long-time medications since admission. Lastly, pt says she has not had a BM since 6 days ago, which is unusual for her. She has been given Miralax and Senna at Bellevue with no relief. She was given one dose of Lactulose here, last night, with no BM after. Pt does admit to passing flatus when sitting on the toilet. Pt does admit to slight loss of appetite since her hospitalization. 

Denies taking anticoagulant, fever, vomiting, diarrhea, abdominal pain, nausea, hematuria, dysuria, urinary retention, numbness/tingling of extremities, hematochezia, and melena. 

PMHx:

Present chronic illnesses-

• Osteoporosis
• Overactive bladder
• Major depressive disorder 

Past medical illnesses- 

• None

Childhood illnesses-

• Denies

Immunizations-

• Up to date, excluding COVID booster (declined)

Screening tests and results-

• Unknown

Past Surgical History-

• Bariatric surgery- 2017

Medications-

• Calcium carbonate 600 mg, 1 tab QD for osteoporosis
• Vitamin D 1,000 IU, 1 tab BID for osteoporosis
• Multivitamin
• Vesicare 10 mg, 1 tab QD for overactive bladder
• Myrbetriq 50 mg, 1 tab QD for overactive bladder
• Zoloft 200 mg, 1 tab QD for depression
• Tylenol 325 mg, 3 tabs Q8H for pain
• Lidocaine patch, 12 hrs on/ 12 hrs off
• Gabapentin 600 mg Q8H for nerve pain
• Methocarbamol 500 mg, 1 tab 4 times/day for muscle pain

Allergies-

• No known drug, food or environmental allergies.

Family History:

• Unknown

Social History:

• S.G. is single, never married and lives alone in a studio in New York City. She is selling the apartment and moving to her second home in Connecticut. The home has 3 steps required to enter, but pt says she can live on the first floor only if necessary. 
• Pt was completely independent in all ADLs and IADLs and received no aid, prior to her most recent fall. 
• Pt says she has friends who can help her upon discharge. Pt has no children or spouse or other living family.
• Pt is a retired nurse.
• Pt denies alcohol intake.
• Pt denies smoking cigarettes. 
• Pt has 1 cup of coffee daily.
• Pt denies illicit drug use.
• Pt denies recent travel.
• Pt says she attempts to maintain a healthy diet consisting of proteins, fruits, vegetables and healthy carbs, but sometimes gets fast food. 
• Pt walks daily to do her errands, without any assistive devices. 
• Pt reports getting about 6 hours of sleep each night, but notes the quality has worsened since her hospitalization.
• Pt is not sexually active.

Review of Systems:

• General: Admits to slight loss of appetite. Denies fever, fatigue, chills, night sweats, weight loss/gain.
• Skin, hair, nails: Denies discolorations, moles, rashes, changes in hair distribution or texture, pruritus.
• HEENT: Denies head trauma, vertigo, visual disturbances, ear pain, hearing loss, tinnitus, epistaxis, discharge, congestion, sore throat, bleeding gums.
• Neck: Denies localized swelling/lumps, stiffness/decreased ROM
• Breast: Denies lumps, nipple discharge, or pain.
• Pulmonary: Denies cough, dyspnea, wheezing, cyanosis, hemoptysis.
• Cardiovascular: Denies chest pain, edema/swelling of ankles or feet, palpitations.
• Gastrointestinal: Admits to constipation. Denies abdominal pain, nausea, vomiting, jaundice, diarrhea, dysphagia, pyrosis, flatulence, eructation, rectal bleeding, hemorrhoids or blood in stool.
• Genitourinary: Denies urinary frequency, nocturia, urgency, flank pain, oliguria, polyuria and incontinence, vaginal discharge, dysuria and malodorous urine.
• Menstrual/Obstetrical: G0P0000, LMP age 51; not currently sexually active
• Musculoskeletal: Admits to back pain and muscle pain. Denies joint pain, arthritis and joint swelling.
• Nervous system: Denies seizures, headache, loss of consciousness, sensory disturbances, ataxia, loss of strength, change in cognition/mental status/memory.
• Peripheral vascular: Denies intermittent claudication, coldness or trophic changes, varicose veins, peripheral edema, or color changes.
• Hematologic: Denies anemia, easy bruising or bleeding, lymph node enlargement, history of DVT/PE.
• Endocrine: Denies polyuria, polydipsia, polyphagia, heat or cold intolerance, goiter, excessive sweating, or hirsutism.
• Psychiatric: Denies feelings of helplessness, hopelessness, lack of interest in usual activities, or suicidal ideations, anxiety, obsessive/compulsive disorder, or ever seeing a mental health professional.

Physical

General:

• Well developed, obese female in obvious discomfort due to back pain. Appears stated age of 66. Neatly groomed, alert and oriented x4. In no respiratory distress.

Vitals:

• BP: 115/75 mm Hg
• R: 17/min, regular rate and rhythm, unlabored
• P: 78 beats per minute, regular rate, rhythm and amplitude 
• SpO2: 97% on room air
• T: 97.3 degrees F (temporal)
• Height: 60 inches Weight: 219 lbs BMI: 42.77

Skin & Head:

• Skin: Warm and moist, good turgor. Nonicteric, no lesions, scars, or tattoos noted.
• Hair: No balding with average texture. No alopecia, seborrhea, or lice on exam.
• Nails: No clubbing, cyanosis, or lesions. Capillary refill < 2 seconds in upper and lower extremities.
• Head: Normocephalic, atraumatic with no evidence of contusions, ecchymoses, hematomas, or lacerations, and nontender to palpation throughout.
• Eyes: Symmetrical OU. EOMS intact, no strabismus, nystagmus, exophthalmos, or ptosis. Sclera white, cornea clear, conjunctiva pink. PERRLA.

Nose/Sinuses:

• Nose: Symmetrical. No masses, lesions, deformities, trauma. No discharge visualized. Nares patent bilaterally. Nasal mucosa is pink and well hydrated. Septum midline without lesions, deformities, injection, or perforation. No foreign bodies.

Mouth/Pharynx:

• Teeth: Good dentition. No obvious dental caries noted.
• Tongue: Pink and well papillated. No masses, lesions or deviation. No fasciculations.  
• Oropharynx: Well hydrated. No injection, exudate, masses, lesions or foreign bodies. Tonsils present with no swelling, injection or exudate. Uvula midline, pink with no edema or lesions.

Thorax and Lungs:

• Chest: Symmetrical, no deformities, no trauma. Respirations unlabored/ no paradoxical respirations or use of accessory muscles noted. Non-tender to palpation throughout. 
• Lungs: Clear to auscultation and percussion bilaterally. No adventitious sounds.

Cardiac Exam:

• Heart: Regular rate and rhythm. S1 and S2 are distinct with no murmurs, S3 or S4. No splitting of S2 or friction rubs appreciated. 

Abdominal Exam:

• Abdomen with round contour with no scars, striae or pulsations noted. Bowel sounds normoactive in all 4 quadrants with no aortic/renal/iliac or femoral bruits. Mild tenderness to palpation, soft and nondistended. No guarding or rebound noted. 

Neuro Exam:

• Cranial Nerves: CN I- XII are intact
• Sensation: Sensation is intact bilaterally to pain and light touch. 
• Motor: Good muscle tone. Strength is 5/5 bilaterally in upper and lower extremities. 
• Cerebellar: Gait not assessed due to pain.

Peripheral Vascular System:

• Extremities are warm and without edema. No varicosities or stasis changes. Calves are supple, equal in size, non erythematous and nontender. Pulses are 2+ and symmetric. 

Musculoskeletal: 

• Bilateral arms: No erythema, warmth or crepitus noted. Non-tender to palpation. Full range of motion. 
• Back and lower extremities: Not assessed due to pain.

Differential Diagnosis:

• Pain secondary to L3 fracture
• Muscle strain
• Pain secondary to spinal stenosis
• Opioid induced constipation

Assessment: 

• 66 year old female with PMHx of osteoporosis hospitalized and treated s/p fall and L3 vertebral fracture. Pt deemed stable for hospital discharge and admission to SAR. Since transfer, pt is experiencing pain due to poor pain control and constipation since the beginning of her hospitalization, likely due to opioid use. At this time there are no labs or imaging to review.  

Plan:

• Weekly weights x1 month

• L3 Fracture/Spinal stenosis
  • PT daily (30 minute sessions)
  • OT daily (30 minute sessions)
  • Pain control
    • TLSO brace
    • Tylenol 325 mg, 3 tabs Q8H 
    • Methocarbamol 500 mg, 1 tab Q6H
    • Gabapentin 600 mg, 1 tab Q8H
    • Lidocaine patch every morning on for 12 hrs, off for 12 hrs
    • Oxycodone 10 mg, 1 tab Q6H PRN 
    • Physiatry consult
    • Acupuncture request

• Constipation
  • Milk of Magnesia 400 mg/5 mL, 30 mL Q24H
  • Sodium phosphate enema 7-19 gm/118 mL, 1 applicator Q24H PRN constipation if MOM ineffective 

• Osteoporosis
  • Calcium carbonate 600 mg, 1 tab QD for osteoporosis
  • Vitamin D 1,000 IU, 1 tab BID for osteoporosis
  • Multivitamin

• Major depressive disorder
  • Zoloft 200 mg, 1 tab QD

• Overactive bladder
  • Vesicare 10 mg, 1 tab QD 
  • Myrbetriq 50 mg, 1 tab QD