Identifying Data:

Full Name: L.S.

Age: 91

Sex: Female

Marital Status: Widowed

Race/Nationality: Caucasian 

Address: Queens, NY

Date of Birth: XX/XX/1930

Date and Time: 7/12/21 10:30 PM

Location: New York Presbyterian Hospital Queens

Religion: Unknown

Source of Information: Nursing Home

Source of Referral: Primary care physician

Reliability: Patient is not reliable secondary to dementia

Mode of transport: EMS

Chief Complaint: low hemoglobin from primary care physician labs

History of Present Illness:

91-year-old Caucasian female, living in skilled nursing facility, ambulating with walker, unable to perform her ADLs and IADLs independently, with a PMHx of dementia, hypothyroidism, and hypertension, who presented to NYPQ ED from nursing home for low hemoglobin. Per nursing home records, patient’s primary care physician took labs two days ago, which showed that the patient had a hemoglobin of 5.8 and hematocrit of 21. Per PCP, patient’s baseline hemoglobin is 9-10.  Nursing home documentation reports the patient had blood in her stools recently. No nursing home documentation of fever, chills, chest pain, palpitations, shortness of breath, cough, abdominal pain, nausea, vomiting, hematemesis, melena, dizziness, syncope, pain, or any other symptoms at this time. No recent falls. History is limited from the patient secondary to dementia.

In the ED, patient’s vital signs remained stable, and she received one liter of normal saline. Guaiac was positive with brown stool. Unable to contact family while in the ED and the patient was transfused emergently with two physician consent with two units of packed red blood cells.

Currently, patient is hemodynamically stable and resting in bed comfortably. She is alert and oriented to person and place. She appears confused, which is baseline per nursing home documentation, but reports feeling well with no complaints.

Geriatric Assessment:

• ADLs: requires assistance with bathing, dressing, grooming ambulating and transferring.
• IADLs: dependent on nursing home staff
• Home health aide: lives in skilled nursing facility
• Social support: in contact with sister 
• Visual impairment: wears glasses for distance
• Hearing impairment: requires repetition of words
• Dental: patient wears dentures – unknown last exam 
• Falls: fall in January 2021 and April 2021
• Assistive device: walker 
• Nutritional concerns: none. Receives chopped diet with good appetite.
• Gait impairment: uses walker
• Urinary incontinence: denies
• Fecal incontinence denies
• Depression: unknown
• Health care proxy: sister
• Advance directives: MOLST form signed DNR/DNI from 01/2021 signed by sister. Patient is DNR/DNI/ with limited medical interventions, no feeding tube and permission for a trial period of IV fluids. 

Past Medical History:

• HTN
• Hypothyroidism
• GERD
• Hemorrhoids 
• Dementia, unspecified type

Past Surgical History:

• Internal fixation of right femur in 01/2021 s/p fall – surgery at NYPQ, with no complications

Family History:

• Unknown

Medications:

• Nystatin 100,000 unit/gram cream apply twice a day
• Omeprazole 40 mg delayed release capsule once a day
• Phenylephrine 0.25% 0.25-14-74.9% ointment once a day
• Zinc sulfate 50 mg once a day
• Multivitamin once a day
• Senna 8.1 two tabs once a day

Immunizations:

• COVID-19: received both doses
• Influenza – 10/2020

Allergies:

• No known food, drug, or environmental allergies

Social History:

• Widowed, lives in skilled nursing facility
• Unknown previous career but retired. Supported by social security income.
• Habits: No present alcohol, tobacco, or illicit drug use.
• Recent travel: denies
• Diet: per skilled nursing facility – healthy diet, eats chopped food with good appetite.
• Exercise: denies
• Sleep: Sleeps approximately 8 hours per night 
• Sexual history: Unable to obtain

Review of Systems: 

Unable to obtain ROS due to patient’s mental status

Physical Exam: 

VS: T 98.3 F, BP 131/71, HR 68 bpm, RR 17, O2 sat 95%, Ht 5’0”, Wt 92 lb, BMI 18.04

Gen: Elderly and frail patient lying on bed in no acute distress. Awake, alert, and oriented to person and place. 

Skin: Pallor. Warm and moist, no rash or bruises. Normal skin turgor. Non-icteric skin. No ulcers.

Head: Normocephalic, atraumatic. Mild temporal wasting.

Eyes: Symmetric OU. No eyelid swelling, ptosis or lesions. Sclera non-icteric. PERRLA. EOMI. Conjunctival pallor.

ENT: Mucous membranes moist. No erythema or exudates in oropharynx. No glossitis or cheilosis present. Uvula midline. Trachea midline, thyroid non-enlarged. No lymphadenopathy. Dentures in place.

Cardiovascular: Regular rate and rhythm, S1. S2 with no murmurs. Radial pulses, DP/PT pulses 2+ bilaterally. Capillary refill less than 2 seconds bilaterally. No peripheral edema. No JVD.

Respiratory: Non-labored breathing. Clear to auscultation bilaterally.

Abdomen: Bowel sounds present in all quadrants. Soft, nontender, nondistended with no rebound or guarding. No masses felt. Rectal exam deferred on admission as patient had guaiac positive exam from ED with no rectal masses felt.

Extremities: Proximal wasting in extremities. Full range of motion of all extremities. Strength grossly intact. No ecchymosis or deformities.

Neuro: Alert and oriented to person and place. Confused. No focal deficit.

Differentials:

• Iron deficiency anemia
• B12 deficiency anemia
• Folate deficiency anemia
• Colorectal cancer
• Anemia secondary to kidney disease
• Acute or chronic blood loss anemia

Labs:

• CBC: WBC 8.96, RBC 3.21, Hgb 5.8, HCT 21.1, MCV 65.7, MCH 18.1, RDW 17.1, platelets 634, differential within normal limits
• CMP: Na 137, K 3.8, Cl 104, CO2 21, BUN 12.9, Creatinine 0.64, glucose 87, anion gap 12, calcium 8.8, BUN/Cr ratio 20, protein 6.0, albumin 3.5, globulin 2.5, bilirubin total 0.2, AST 11, ALT 10, Alk phos 89
• T&S: B+
• SARS-COV-2-NAAT: Not detected
• PT 14.3, INR 1.24, PTT 32.3

Assessment/Plan:

91-year-old Caucasian female, living in skilled nursing facility with a PMHx of dementia, hypothyroidism, and hypertension who presented to the ED from nursing home for low hemoglobin of 5.8. Patient was guiaic positive with brown stool in the ED and received one liter normal saline and 2 units of PRBCs.

• Anemia
  • Occult positive, brown stool on exam
  • Hemoglobin 5.8, Hematocrit 21
  • Two units of PRBCs ordered and transfused in the ED
  • Transfusion threshold of hemoglobin below 7
  • Follow up post-transfusion CBC and will continue to trend CBC
  • Ordered transferrin, iron, total iron binding capacity, iron saturation, ferritin, B12 and folate
  • Keep patient NPO
  • Maintain type and screen and 2 large bore IVs
  • Ordered Protonix 40 mg IV every 12 hours
  • Consult GI – if GI recommends, will get EGD/colonoscopy
• Hypertension
  • Not on any medications as per nursing home medication list
  • Will monitor blood pressure
• Hypothyroidism
  • Not on any medications as per nursing home list
  • Will order TSH and T4
• DVT prophylaxis
  • Will hold anticoagulation
  • Will order intermittent pneumatic compression
• Dementia
  • Xanax as needed for agitation