H&P #2

Identifying Data

Full Name: N. T.

Sex: Male

DOB: xx/xx/1956

Date & Time: September 6, 2023

Location: New York Presbyterian Queens

Religion: Unknown

Source of Information: Self

Reliability: Reliable

Source of referral: Self

 

Chief Complaint: “I tripped and fell” x 1hr

 

History of Present Illness:

67 y/o M with PMHx diabetes presents to the ED s/p fall c/o facial trauma 1 hour prior to arrival. Patient endorses a mechanical fall, stating he was walking down the steps by the entrance to his house when he missed a step and fell face forward. Patient states he was on the ground for about 2 minutes with no known LOC before being found by family. As per family, patient was able to stand with assistance after fall. Patient states he is currently able to ambulate normally. Patient denies prodromal symptoms prior to fall such as chest pain, dizziness, SOB or palpitations. Patient currently has no complaints of pain. Denies active bleeding, vision changes, headache, dizziness, syncope, chest pain, SOB, vision changes. Patient states he does not use blood thinners.

On arrival to the ED patient was bradycardic to 48 bpm and an EKG was completed. EKG demonstrated third degree heart block and patient was transferred to CEU to be placed on continuous cardiac monitoring, continuous pulse oximetry, intermittent BP checks and zoll pads.

 

Differential diagnosis:

  1. Fracture
  2. Contusion
  3. Domestic abuse / assault

 

Past Medical History:

Medical History:

  • Diabetes mellitus type 2

Medications:

  • Metformin 850mg 1 tablet BID
  • Denies OTC medications.
  • Denies herbal supplement use.

Surgical History:

  • Left knee replacement 2016, no records, no reported complications

Allergies:

  • No known drug/food/environmental allergies

Family History:

  • Mother: Deceased age 82 from HF. Hx HTN, HLD.
  • Father: Deceased age 74 from lung cancer (unknown dx age).
  • Brother: age 59, hx HLD
  • Paternal uncle: colorectal cancer (unknown dx age)
  • 1 son, age 31, alive and well

Social History:

  • Smoking: Smoked cigarettes. 10 pack-year smoking history. Quit 21 years ago.
  • Alcohol: denies
  • Denies past or current illicit drug use
  • Marital History: Married for 10 years.
  • Language: English. Able to read and write.
  • Education: High school graduate
  • Occupational History: Unemployed.
  • Travel: No recent travel
  • Home situation: Lives in Queens apt on 8th floor with elevator. Lives with wife.
  • Sleep: Patient states he sleeps about 8-9 hours per night
  • Exercise: Denies regular exercising
  • Diet: carbohydrate heavy diet, limited vegetables
  • Caffeine: denies caffeine use

 

ROS:

  • General:. Denies fever, fatigue, chills, night sweats, weight loss, changes in appetite.
  • Skin, hair, nails: Denies discolorations, moles, rashes, changes in hair distribution or texture, pruritus.
  • HEENT: Admits to head trauma, facial swelling and sinus pressure. Denies vertigo, visual disturbances, ear pain, hearing loss, tinnitus, epistaxis, discharge, congestion, sore throat, bleeding gums. Patient states last dental visit was about 4 months ago.
  • Neck: Denies localized swelling/lumps, stiffness/decreased ROM
  • Pulmonary: Denies cough, dyspnea, wheezing, cyanosis, hemoptysis.
  • Cardiovascular: Admits to leg swelling. Denies chest pain, palpitations.
  • Gastrointestinal: Denies abdominal pain, diarrhea, constipation, N/V.
  • Genitourinary: Denies urgency, frequency, incontinence, hesitancy, dribbling.
  • Musculoskeletal: Denies muscle pain, joint pain, arthritis, or swelling.
  • Nervous system: Denies headache, loss of strength, change in cognition/mental status/memory.
  • Hematologic: Denies anemia, easy bruising or bleeding, lymph node enlargement, history of DVT/PE.
  • Endocrine: Denies polydipsia, heat or cold intolerance, excessive sweating.
  • Psychiatric: Denies depression or anxiety.

 

Physical Exam:

Vitals:

  • Weight: 230 lb Height: 66 inches       BMI: 38.11 kg/m2
  • BP: 138/65, right arm sitting
  • RR: 14
  • HR: 48 bpm
  • Temp: 98.4 F oral
  • SpO2: 96% room air

General: 67-year-old obese male who is speaking in full sentences, appears in no acute distress. AO x 3.

Head: Normocephalic.

Eyes: Mild swelling and ecchymosis near RIGHT orbit. PERRLA. EOMI. No active bleeding.

Ears: Symmetrical. No otorrhea or blood visualized in canal. Hearing grossly intact.

Nose: Non tender to palpation. Nares patent. No rhinorrhea. No nasal hematoma noted.

Sinus: Tenderness to right maxillary sinus.

Mouth/Throat: TMJ w/ full ROM, no tenderness and no deviation on opening/closing. Uvula midline. Tongue freely mobile. Fair oral hygiene, no teeth mobility.

Neck: Trachea midline. Neck supple and non-tender. No lymphadenopathy present.

Heart: Bradycardic. S1 & S2 present. No murmurs.

Lungs: Clear to auscultation B/L. No adventitious sounds noted.

Abdominal: Abdomen symmetric and non-distended, with no scars. Normoactive bowel sounds in all 4 quadrants. Soft, non-tender to palpation and tympanic throughout with no guarding or rebound.

Musculoskeletal: Full active/passive ROM. Sensation intact B/L. B/L LE swelling with 1+ pitting edema. No calf tenderness. Pulses 2+ B/L.

 

Labs:

CBC: HGB 13.3, HCT 41.8, PLT 235, WBC 6.97

BMP: NA 141, K 4.6, CL 106, CO2 23, BUN 18.2, CR 0.82, GLU 125, ANION GAP 12, CA 9.2

APTT: 41.2; INR 1.34

TSH: 1.80

Pro BNP: 1,720

 

Imaging:

CT Maxillofacial without IV Contrast:

Comminuted fracture of the anterior and posterolateral right maxillary sinus walls noted.

Nondisplaced right orbital floor fracture seen. Nasal bones are intact. Leftward deviation of the bony nasal septum again seen. Zygomatic arches and pterygoid plates are intact. The mandible is intact. Small amount of blood products are seen in the right maxillary sinus. Right periorbital soft tissue swelling. The globes are intact.

CT head without IV contrast:

There is no acute intracranial hemorrhage. No extra-axial fluid collection, mass, mass effect, or herniation pattern

CT cervical spine without IV contrast: No acute fracture

Chest XR:

Parenchyma of the lungs: No infiltrate or pneumothorax. Heart: Enlarged. Indistinct pulmonary vascularity. Pleura: Without evidence of pleural effusions or pleural-based masses. Mediastinum and hila: Without mass.

Pelvis XR:

No acute fracture or dislocation detected.

 

Assessment/Plan:

67 year old male with a history of diabetes mellitus, who presented to ED after a mechanical fall, found to have clinically asymptomatic complete AV block.

 

#Complete heart block – clinically asymptomatic

– Consult cardiology

– Echo

– Permanent pacemaker placement scheduled for tomorrow

– Atropine at bedside in case of hemodynamic instability

– NPO after midnight

– Hold any ACs

– Monitor on tele

 

#Right maxillary sinus fracture

– Augmentin 875-125mg PO bid x 5 days

– Ocean nasal spray prn congestion x 7 days

– Ice packs to face x 3 days, 20 min on/off intervals

– Sinus precautions given to patient

– Follow up appt with New York Presbyterian Queens Center for Dental and Oral Medicine in 1-2 weeks

 

#Diabetes

– Hold metformin

– Initiate insulin sliding scale

– Monitor FS

 

Diet: carbohydrate controlled diet (60 gm/meal)

GI ppx: protonix PO daily

DVT ppx: SCDs

Code status: full

 

Patient Education:

Heart Block:

  • The heart has 4 chambers – 2 atria and 2 ventricles. The atria receive blood and then pass the blood to the ventricles which are responsible for pumping the blood to the body or to the lungs.
  • A third degree heart block occurs when there is no communication between the atria and ventricles. This results in a heart that can’t effectively function. Your heart beats more slowly and blood can’t be pumped out as efficiently as it normally would.
  • Complications of heart block include a heart attack, heart failure, or sudden cardiac arrest.
  • Treatment for a 3rd degree heart block is a permanent pacemaker placement.
  • A pacemaker is a small implanted decide that sends electrical pulses to help your heart beat at a normal rate and rhythm.
  • A small incision in your chest wall is made generally under local anesthesia and the device is implanted right under the skin of the chest.
  • Risks for placement procedure is < 1%, which includes but not limited to bleeding, infection, vascular injury, pneumothorax, cardiac perforation/tamponade, lead dislodegement, CVA, MI, death.

Maxillary Fracture:

  • Maxillary sinus fractures are typically caused by blunt force trauma to the face.
  • Conservative management is typically used, meaning surgery is typically not needed
  • Antibiotics are given to prevent sinusitis.
  • Sinus precautions: no pressure to face, no heavy lifting, no nose blowing, no use of drinking straw, sneeze with mouth open, no swimming or flying for 2 weeks
  • Maintain oral hygiene, gently brush teeth twice a day
  • Please return to ED if fever develops, there is difficulty breathing or swallowing, or if signs of infection develop or worsen (subjective fever/chills, discharge, new onset swelling, foul drainage/odor/taste), or if there are any changes to vision including but not limited to double vision, decreased visual field, limited range of motion of eyes.
  • Follow Up: Please call to schedule follow up appointment in 1-2 weeks at (718) 670-1060