She is Allergic to DEMEROL - CHEST - CARDIAC - ABDOMEN - EXTREMITIES

HISTORY

The patient is an 84-year-old female who called 911 last night around 11 o'clock.  She said during the day she had just felt kind of weak.  She said to one of her neighbors on the phone that said she was not speaking as clearly, but she noticed both hands were weak and she had dropped some things, but during this whole episode and timeframe, which was about 7 hours, she said about 4 or 5 o'clock in the afternoon, she managed to wash dishes and feed herself.  She did not take any of her night medicines because she was kind of concerned and she started thinking she might be having a stroke, so she just stayed home until she went to sleep, then she woke up, because she never could go to bed worrying about something was wrong with her, so she called 911.  They came and evaluated her and brought her to the emergency room with all her medications.  She states she did not take her nighttime medicine of Betapace or the Klonopin or Mirapex for restless legs because she did not want to interfere with anything. 

ALLERGIES

She is allergic to DEMEROL.

CURRENT MEDICATIONS

Include: 

1.            Norvasc 5 milligrams a day.

2.            Hyzaar 100/25 milligrams a day.

3.            Betapace 80 milligrams b.i.d.

4.            Mirapex 0.25 at night.

5.            She has been taking Relafen 500 b.i.d. intermittently for arthritis.

6.            She has Soma tabs as needed for muscle pain.

7.            She takes Klonopin 1 milligram at night for sleep.

8.            She takes GoLYTELY on a p.r.n. basis for constipation.

PAST MEDICAL HISTORY

She has a history of atrial fibrillation for the past number of years.  She is intolerant to the Coumadin as she has had falls.  She is now walking with a walker and is not the most stable person.  She lives at home with a sitter coming in 3 to 4 times a week and friends taking over because she is a widow, with no immediate family close by except in Mobile.  She had a right hip fracture 10 years ago and after that had a DVT.  She had bladder surgery about 2 years ago for bladder tack.  She has had hypertension for a number of years and restless legs syndrome and insomnia for a number of years.

FAMILY HISTORY

Noncontributory.

SOCIAL HISTORY

She is widowed.  She has a son who is estranged, she has not seen for years.  She has 2 granddaughters in Mobile to check on her.  They have been asking to come to Mobile for years, but she is always refusing because they have young kids and she does not want to interfere with their life, so she has lived at home.

REVIEW OF SYSTEMS

Patient was on Coumadin a while for the atrial fib, sustained a fall.  Balance got progressively worse, and it was felt that she is not a candidate for Coumadin any longer secondary to her risk to falls, and she uses a walker at this time.

OBJECTIVE

VITAL SIGNS:  In the ER, her blood pressure 187/106, her pulse is 98, O2 sats are 96.

GENERAL:  Her speech is clear and I can understand every word she says, but it sounds almost lethargic, but she said she has not slept all night.  I see her at 7:30 in the morning, and she said she has been in the ER since 1 o'clock and they did not get her up to a room until 5:30, and she told the nurses that she was just tired, and that was possibly it.

HEENT:  Her pupils are equal, round, and reactive to light.  Her extraocular movements are intact.  Her oropharynx, she has an equal smile.  Her speech is understandable.  She can close her eyes tight.

CHEST:  She has bilateral breath sounds, clear.

CARDIAC:  Her cardiac exam revealed an irregularly irregular rhythm, but rate controlled in the 80s.

ABDOMEN:  Her abdomen is soft.

EXTREMITIES:  She has bilateral nonpitting edema, which is chronic.  Her left leg is worse than the right.  This is the one that she had sustained the DVT, and then she also had trauma to it a few years back with a golf cart incident.

NEURO EXAMINATION:  She is alert and oriented x4.  She knows her address, where she lives and home or social situation, but she is very obstinate in that she is going to go back home if possible.  She has a negative ulnar drift.  She has equal grip strength.  Both legs move okay, the right leg moves a little stiffer secondary to hip replacement.  She has got equal strength, albeit weak, but this is a chronic finding in this lady.

GU AND RECTAL:  Deferred at this time.

IMAGING

EKG showed atrial fibrillation.  CT scan of the head was read with some old cerebellar ischemia, but nothing new on this time.

LABORATORY DATA

Laboratory data reviewed.

ADMISSION DIAGNOSES

1.            Cerebrovascular accident versus transient ischemic attack.  At this time, she seems to be back to her baseline, although she was lying in bed and I did not get her up and walk her, but she seemed to be back to baseline.  She says that she can get up and go to the restroom.

2.            Chronic atrial fibrillation.  Patient is not on Coumadin any longer.  She is at risk for falls and has fallen, and she walks with a walker.

3.            Hypertension, elevated in the emergency room, but now has come down.

4.            Restless legs syndrome.

5.            Status post right hip fracture.

6.            Advanced age.

7.            Hypokalemia.

8.            Hypomagnesemia.

PLAN

At this time, I am going to consult neurology.  __________ has seen her husband.  That is one person she knows.  We will call and see if he is in town.  We will get echo and carotids.  We will also start on a full aspirin a day since she has been on a baby aspirin.  We will get speech and PT evaluation, monitor her blood pressure, replace her magnesium and potassium