Review the patient information below and submit complete and…
Review the patient information below and submit complete and thorough Admission Orders in the following essay question. Patient Name: Mia Johnson Age: 59 years old Gender: F Chief Complaint: “I slipped and fell in my bathroom and now my left hip really hurts” HPI: The pt is a 59 y/o F who presents s/p slip and fall at home. The pt reports she slipped on a wet floor, landing on her left side. She states she immediately felt pain in the upper left leg and could not stand up after the fall despite assistance from her husband due to pain with attempted weight bearing. She did report some potential crepitus upon attempting to stand. The fall occurred approximately 1 hour prior to arrival. The pain is better with sitting still. The pain radiates down the affected leg at times. The pain is currently rated 8/10. She denies any symptoms preceding the fall such as dizziness or presyncope. Pt states that her head landed on the bathroom carpet and denies HA, neck pain, or loss of consciousness. She states that she can remember the whole event and recalls yelling for help from her husband after the fall. She has not been able to remove her pants to see if she has any bruising, but did not see any blood on her clothing. Associated symptoms include nausea without vomiting. Pt denies chest pain, dizziness, numbness/tingling anywhere, confusion, or memory loss. Pt denies hx of a bleeding disorder, the use of any blood thinners, or use of any alcohol / drugs recently. Past Medical History (PMHx): Illnesses/Injuries: Stage 2 CKD due to IgA Nephropathy Hypertension Papillary thyroid cancer (now resolved) Hypothyroidism (due to thyroidectomy) Osteoporosis Hypercholesterolemia Hospitalizations: Pneumonia (3 years ago) Hyponatremia (2 years ago) Surgical History: Right total knee replacement (2 years ago) Thyroidectomy (5 years ago) Screening/Preventive History: Pt is up-to-date on all vaccinations and preventative screenings, including Tdap/Tetanus, pneumonia, COVID, and influenza. Medications (Prescription, Over the Counter, Supplements): -LIsinopril 20mg PO daily -Risedronate (Atеlvia) 35mg once weekly -Vitamin D3 20mcg (1000 I/U) PO daily -Levothyroxine 50 mcg PO daily -Rosuvastatin 10mg PO daily Allergies (e.g. environmental, food, medication and reaction): NKDA Family Medical History: Mother (deceased, age 90) has history of Dementia, Osteoporosis, lupus Father (decreased, age 88) has history of Hypercholesterolemia, HTN, DM2 Sister 1 (alive, 55) has history of depression and alcohol abuse Daughter 1 (alive, 27) – healthy Son 1 (alive, 29) – healthy Family history of osteoporosis on pt’s mother’s side Social History: Substance Use / Alcohol Use: Remote hx of tobacco use (1 pack daily for 10 years before quitting at age 40). No substance abuse/use reported. Pt quit drinking alcohol 20 years ago. Previously, pt would drink on special occasions only. Diet: No special diet reported Home Environment: Lives with husband in their single-story home. No stairs inside, but there is a single step to get inside the home. Occupation: Retired 5th grade teacher Leisure Activities: Pt likes to garden, take the family dog or a walk, or walk with her friends at the beach or local park. Pt also is an avid photographer. Exercise: Active 3-4x per week, near-daily walking Sleep: 6-7 hours per night Religion: Atheist Sexual: Sexually active only with his husband. No hx of STD/STD. ROS (Review of Systems): General: No weight loss, fever/chills, or night sweats. Skin: See HPI. No eczema, dry skin, or skin changes reported. HEENT: No headache, neck pain/stiffness, no sore throat. No vision changes or double vision. No congestion/runny nose. Respiratory: No cough, shortness of breath or wheezing. Cardiovascular: No chest pain or palpitations. Gastrointestinal: No n/v, diarrhea or constipation. No reported abdominal pain, flank pain, or change in bowel consistency. Genitourinary: No change in urination, dysuria, hematuria, or increased urinary frequency. Musculoskeletal: See HPI. No back pain or neck pain reported. Psychiatric: No depression, anxiety, or thoughts of self harm. Hematologic: Pt does report that she occasionally bruises easily but this has been a long-standing issue for her. She denies easy gum bleeding or bleeding problems otherwise.. Endocrine: No hot or cold intolerance or new hair/skin changes recently. Neurologic: No dizziness, headache, confusion, or disorientation. No numbness or weakness reported. Physical Exam: Vital Signs: Temperature: 97.8*F / 36.6 *C Heart Rate: 90 beats per minute Blood Pressure: 140/82 mmHg Respiratory Rate: 20 breaths per minute Pulse Oximetry: 98% on RA Weight: 105 lbs / 47.6 kg Height: 62 inches / 157.5 cm Physical Exam (continued): General: Pt appears uncomfortable, in acute pain at times during the exam. She is wearing street clothes upon arrival. Pt is alert and cooperative, answering questions appropriately. Skin: Upon inspection of the skin, there is ecchymosis and a focal hematoma visible over the lateral upper thigh area without laceration or abrasion. No lacerations or active bleeding visualized on the remainder of the skin exam. The skin is warm, without rashes, has normal turgor, and no pallor or cyanosis noted throughout, including distal B/L LEs. Head: Normocephalic, atraumatic. No obvious signs of head trauma on exam such as contusion, abrasion, bruising, or laceration. Eyes: PEERLA B/L, EOMI B/L, sclera anicteric, conjunctiva clear. Ears, Nose, Throat: Normal ear, nose, and throat inspection. No pharyngeal erythema or lymphadenopathy noted. Ear canals patent B/L. Hearing grossly intact B/L. No hemotympanum, raccoon eyes, Battle sign, or otorrhea noted. Neck: Non-tender, c-spine ROM intact, no midline TTP, step-offs, or deformity. No visible skin changes, contusion, or abrasion. Pulmonary: Lungs clear to auscultation B/L, no crackles, wheezes, or rhonchi. Cardiac: Tachycardia noted, with normal rhythm, no murmurs, gallops, or rubs. Normal S1 and S2 otherwise. Peripheral Vascular: Capillary refill less than 2 seconds throughout distal extremities bilaterally. Peripheral pulses full and equal bilaterally, most notably 2+ radial pulses B/L with normal capillary refill of L hand (as well as R hand) Abdomen: Soft, non-distended, non-tender. Normoactive BS presents in all 4 quadrants. No signs of abdominal trauma such as contusion, abrasion, or bruising. Rectal: Deferred GU: Normal external genitalia without evidence of trauma or injury. MSK: Cervical, thoracic and lumbar spine are without midline tenderness, step-off or deformity. Pelvis stable and without TTP. No crepitus, or depression appreciated. The left leg appears shortened on general exam when compared to the right and is sitting internally rotated on the initial exam. No gross deformity immediately appreciated. Crepitus was felt when attempting to externally rotate the hip or flex it toward the pt’s trunk, therefore the remaining of the upper hip area exam was withheld. The L knee also was difficult to assess due to proximal pain, but appeared to have normal ROM, and landmarks. L ankle and foot appears normal, with ROM intact. There is TTP along the upper thigh and at the greater trochanter landmark. R lower extremity appears without evidence of contusion, deformity, or swelling. ROM intact at R hip, knee, ankle, and foot B/L upper extremities WNL at all major joints, without limitation of ROM, deformity, or crepitus. Neuro: Pt is AAOX4. Memory and recall intact of the fall and recent events. Sensation noted to be intact and present throughout all extremities. No obvious gross motor or sensation deficits of areas assessed. Strength 5/5 all extremities at major joints with exception of L hip and knee, which could not be accurately assessed due to pain and concern for fracture. CN 2-12 exam is otherwise grossly intact, but pt’s gait could not be assessed. Reflexes 2+ RLE, B/L upper extremities, and distal L achilles, but L patellar reflex was not assessed due to pt’s pain. No tremor noted. Psychiatric: Appropriate mood and affect for situation