Site Evaluator: Dr. Davidson
I presented the following case at my first site evaluation:
FS is a 91 y/o female with a PMHx of HTN, HLD and osteoporosis who presented to Queens Hospital Center ED last night after a fall. At baseline, she lives alone, is ambulatory – walks without any assistive devices at home and uses a cane when outside, is completely independent in her activities of daily living and independent activities of daily living including driving, and has full cognitive capacity – she states she is able to care for herself. Pt was standing near her kitchen when she lost her balance and fell backwards. Pt hit her back but not her head and remembers the whole fall, denying any loss of consciousness. She states she was on the floor for 24+ hours as she couldn’t get up or access her Life Alert which she usually wears as a necklace but happened to not be wearing it. She relays that she doesn’t know how but she was called through the Life Alert system and was able to notify the emergency response team that she had fallen and could not get up. Pt admits to lower back pain, and a hx of falls, other incident 3-4 years ago after tripping while walking and was unable to get up from the floor. Pt admits to tenderness in her lower back where she fell onto. Pt denies loss of consciousness, dizziness, head pain or trauma, swelling of her legs, jerking movements of her extremities, diaphoresis, chest pain, palpitations, N/V, dysuria or incontinence although she did wet herself as she was on the floor for a little over 1 day. No new medications started or change in medication or doses.
Pt was given Tylenol 975 mg and 1L NS in the ED and was admitted to the medicine floor.
Patient’s PMHx is significant for HLD, HTN and osteoporosis. Past surgical hx includes bilateral hip replacement in 2009, done 6 months apart. Pt is taking Amlodipine 5 mg daily, Simvastatin 10 mg daily and is compliant with her medication.
Patient’s vitals: BP – 143/80, pulse – 98 bpm regular, RR – 18 breaths/min unlabored, T – 98.2 degrees F oral, O2 sat – 98% on room air, BMI – 22.3. PE is remarkable only for tenderness upon palpation in lumbar region of her lower back and a club L foot which doesn’t have lateral movement.
Patient’s labs remarkable for: WBC – 13.34, BUN – 33, eGFR – 54, AST – 85, troponin T – 0.021, CPK – 2246 and lactate – 2.3. Imaging is mainly unremarkable except for some ischemic changes on EKG and CT head without contrast.
Patient fell likely due to mechanical causes with elevated CK; on fall precautions, given IV hydration with LR 100 cc/hr, trending her CK, social work evaluation as the patient lives alone and may benefit from HHA and PT consult for possible SAR placement. Also trend troponins and EKGs, cardiac monitoring for 24 hours.
Dr. Davidson was so helpful as always! She listens extremely carefully and writes down her questions so as not to miss anything. She questioned me which made me think and corrected me in areas which needed correcting or clarifying. Her detailed feedback on my first H&P allowed me to fix my mistakes for my 2nd and 3rd and learn from my errors. She both critiqued and complimented when necessary. Most importantly she offered tons of information and stories which helped me learn and added a lot to my knowledge of LTC!
