History of Present Illness
Acute Phase
Ms. Mondragon is a thin, 71-year-old, widowed Hispanic Spanish-Speaking woman whose son is serving as interpreter in the emergency department. Ms. M. fell this morning in her kitchen.
She presents with upper back pain, groin pain, and left hip pain radiating anteriorly to the knee. There is radiographic evidence of compression fractures at several levels of the thoracic spine. Left hip x-rays are negative for fracture but positive for arthritic changes.
Past Medical History
- History of substance abuse from 20s to 40s – alcohol, marijuana
- Current use of snuff
- COPD
- Hypertension
- Osteoporosis
- Pertinent medical history: pneumonia w/ hospitalization X 2 in past 5 years, history of smoking (35+ pack-years).
Past Surgical History
- Negative
Fall History
- Son reports frequent stumbling
Current Medications
Nasal O2 1.5 L at night
Triamterene/hydrochlorothiazide 37.5 mg/25 mg daily
Risedronate 10 mg wkly
Allergies
No known drug allergies
Family History
Positive for current heroin use in one son.
Physical Exam
Vital Signs
- Blood pressure: 116/62
- Pulse: 92
- Respiration: 20, shallow
- O2 sat = 92% room air
IASP Faces Pain Scale
General appearance
Thin, older woman, mild distress.
Lungs
Soft expiratory wheezes, otherwise clear
Heart
Regular rhythm, no murmurs
Abdomen
Soft, palpable liver tip, no masses, no tenderness on palpation
Extremities
Facial grimacing with left trochanteric manipulation, including flexion, adduction, and internal rotation; walking is painful
Skin
No rashes
Musculoskeletal
Diminished strength in upper and lower extremities
Neurological
Alert, pleasant 71-year-old female; oriented X 3
Ms. Mondragon: ACUTE PHASE Lab Results
- ESR: 38
- CBC
- WBC: 4400
- RBC: 3.6
- Hgb: 12.5
- Hct: 31% (34.9 - 44.5 female range)
- Chem 7
- Glucose: 125
- Na: 130
- K+: 5.0
- Cl-: 102
- BUN: 20
- Creatine: 1.3
- Co2: 27
- UA
- SG: 1.030
- pH: 6
- Leukocyte: +
- Blood: -
- Protein: -
Normal adult hematocrit values vary between 38.8 and 50 percent for men and 34.9 and 44.5 percent for women. Normal adult hemoglobin values are generally 13.5 to 17.5 grams per deciliter for men and 12 to 15.5 grams per deciliter for women.
Cancer, kidney or liver failure, or chronic condition increases risk of “anemia of chronic disease”. These conditions can lead to a shortage of red blood cells.
Discharge Orders
- It is determined that the thoracic compression fractures are related to severe osteoporosis and will be managed with opiates and bed rest.
- One tab: 2.5 mg oxycodone/325 mg acetaminophen every 4-6 h prn, severe pain (Faces Pain Scale ≥ 4)
- Two tabs: 325 mg acetaminophen prn every 6 h mild pain (Faces Pain Scale ≤ 3 or less)
- Patient is dehydrated.
- Increase fluids
- Patient is to follow up with the orthopedist in 2 weeks.
- Patient is discharged to home with her son.
- Walker provided
- Discharge orders read to son; son agrees to call for any concerns
