H&P: Millie Larsen
HPI:
Ms. Larsen was admitted to the Emergency Department after being brought in by her daughter became
who stopped by and found her still in her bathrobe at 5:00 PM. Ms Larsen was confused to the point
that she could not remember her daughter’s name. Millie was brought to the emergency department by
her daughter and spent the night there before being admitted to the general medical-surgical unit
around 9:30 AM.
ROS:
General: no fatigue, weight loss or gain, fever, chills, or night sweats
Eyes: no visual changes, pain or redness
ENT: occasional throbbing headaches (bi-temporal) lasting 1-2 hours and relieved with APAP or IBU, no
hoarseness, no sore throat, no epistaxis, no sinus symptoms, no hearing loss or tinnitus
CV: no chest pain, edema, PND, orthopnea, palpitations or claudication
Resp: No cough, SOB, wheezing
GI: No abdominal pain, stool changes, nausea/vomiting, diarrhea, constipation, heartburn or blood in
stool
GU: No dysuria, frequency, hematuria, vaginal discharge. Postmenopausal. Has had occasional urinary
incontinence following coughing and laughing for past year.
Musculoskeletal: Pain in both knees, worse in evening after working/walking all day, no joint swelling or
redness, no myalgias, no back pain.
Heme/Lymph: No abnormal bleeding or bruising, no transfusions or lymph node swelling.
PMH:
HTN since 2000
Hypercholesterolemia- diagnosed September 2015
Glaucoma since 2005
Postmenopausal- LNMP 1975
Osteoarthritis- both knees
Stress incontinence x 1 years
Past Surgical HX:
Cholecystectomy at age 30
Family HX:
Spouse- Deceased, age 91
Daughter- Age 50, alive and healthy, named Dina
3 Grandkids- age 17, 14 and 12- alive and healthy
Social HX:
Widow, married 68 years, husband died 2014
Active in Lutheran church choir and kitchen
Pets; 1 cat (Snuggles)
Hobbies: gardening, cooking
Never smoked, drank ETOH or used illicit drugs
Meds:
- captopril 25 mg po three times a day
- metoprolol 100 mg every day
- furosemide 40 mg po twice per day
- Lipitor 50 mg once daily
- pilocarpine eye drops 2 drops each eye 4 times a day
- Celebrex 200 mg po once a day
- tramadol 50 mg po every 4-6 hours prn pain
Allergies:
- NKDA
Immunizations:
- Influenza and Pneumococcal- 2013
Physical Exam:
General:
- Alert and oriented x 3, does not remember confusion incident yesterday
- BP: 152/94, P. 64 and regular, R. 14 and unlabored, T. 98.2F, weight: 48Kg, height: 61 inches, BMI=20
HEENT:
Scalp atraumatic, hair normal pattern, texture and distribution
Eyes: PERRLA, fundi without AV nicking or exudates, no obvious papilledema
Ears: EACs clear and atraumatic, TMs pearly grey and translucent, hearing grossly intact to voice and
whisper
Nose: nares patent bilaterally, septum intact, no discharge, polyps or bleeding
Mouth: Edentulous with upper and lower dentures, gums intact without redness or lesions, oral mucosa
somewhat dry, pharyx non-erythematous without exudate, uvula midline
Neck: supple, full and nontender ROM, no bruits, no lymphadenopathy, no thyromegaly
Chest: symmetric and nontender with normal AP diameter
Lungs: clear to auscultation bilaterally, no abnormal lung sounds
Heart: rate and rhythm regular, no murmurs, rubs or gallos
Abdomen: Soft and nontender, well-healed surgical scar upper right quadrant, bowel sounds
normoactive, no hepatosplenomegaly
GU: deferred
BACK: Full ROM, no spinal tenderness, no CVA tenderness
EXTS: upper and lower extremities with grossly full ROM. No joint swelling, pulses 4+ and equal
bilaterally. No calf tenderness. Both knees painful with ROM with mild crepitus.
LABS from ED:
UA:
Color: dark amber, cloudy
Specific gravity: 1.050 (normal 1.005-1.035)
ph 6.0 (normal 4.5-8.0)
Pro: neg
Urobili: 1.0
Nit: Pos
Leu: Pos
Urine Micro:
RBC - 9 (normal 0-2)
WBC - 150,000 (normal 0-5)
Basic Metabolic Panel
Na – 149 mmol/L
K - 3.5 mmol/L
Glucose - 105 mg/dL
CBC
Hgb: 9.9 mmol/L
Hematocrit: 32 %
MCV: 72 fL
MCHC: 29 g/dL
WBC 12,000
Impression:
1) Acute confusional episode
2) Mild dehydration
3) Urinary tract infection
4) Hypertension- uncontrolled
5) Postmenopausal
6) Osteoarthritis
7) Stress incontinence
8) Glaucoma
Plan:
1) Admit to 6E
2) Out of bed with assistance
3) Regular, low-fat diet
4) IV fluids D5 .45 NaCl 20 mEq KCL at 60ml/hr
5) I&Os, vitals q shift
6) Continue home meds:
- captopril 25 mg po three times a day
- metoprolol 100 mg every day
- furosemide 40 mg po twice per day
- Lipitor 50 mg once daily
- pilocarpine eye drops 2 drops each eye 4 times a day
- Celebrex 200 mg po once a day
- tramadol 50 mg po every 4-6 hours prn pain
7) Ciprofloxacin 200 mg IV q 12 hours
8) Acetaminophen 325mg q 4-6 hours prn pain or fever
9) Labs: Send urine for C&S if not done in ED, repeat CBC, UA, CMP daily
10) PT and OT evaluation and treatment
Signed,
Dr. Eric Lund