Identifying Data:

Full Name: C.H.

Age: 75

Sex: Male

Marital Status: Single

Race/Nationality: African American   

Address: Queens, NY

Date of Birth: XX/XX/1946

Date and Time: 10/20/2021 4:30 AM 

Location: New York Presbyterian Hospital Queens   

Source of Information: Self/EMS

Source of Referral: EMS

Reliability: Reliable

Mode of Transport: EMS

Chief Complaint: “I passed out at the grocery store” just prior to arrival   

History of Present Illness: 

75 y/o M, with a PMHx of HTN, BPH with current Foley in place, urinary retention and recurrent UTIs, who presents to the ED via EMS after a syncopal episode at the grocery store two hours ago. The patient states he was at the store when he felt weak and had to lay down and fell to the ground hitting his right shoulder. Patient reports loss of consciousness for a few seconds. He denies hitting his head or taking any blood thinners. He denies shortness of breath, chest pain, diaphoresis, palpitations, headache, weakness, dizziness, fatigue, fever, chills, nausea, vomiting, diarrhea, or hematuria before or after the episode.

In the ED patient received 1L fluids and Td vaccine. Workup revealed a white count of 29.42 and positive UA. CT head was negative for any acute abnormality. CXR and XR right shoulder also negative. Patient was found to have sinus bradycardia at 56 bpm. Patient will be admitted to medicine for syncope.

Upon chart review, patient has a history of leukocytosis with WBC in the 20s. Patient was supposed to follow up with heme/onc after his last hospital discharge a month ago but never did.

Patient was also seen in the ED three weeks ago for urinary retention and UTI, with a baseline creatinine at 1.7 and urine culture positive for E. Coli and was discharged with a foley. Patient was supposed to see the urologist this Friday (10/22) for follow up. Patient has a history of bradycardia in previous admissions with no symptomatic episodes.

Past Medical History:

• Present illnesses:
  • Hypertension, unknown how long
  • Benign prostatic hypertrophy, unknown how long
  • Recurrent urinary tract infections, unknown how long, last UTI three weeks ago

Past Surgical History:

• TURP in 2019, no complications.

Family History:

• Non-contributory family history

Medications:

• Hydralazine 75 mg PO every 8 hours
• Losartan 25 mg PO daily
• Amlodipine 5 mg PO daily
• Tamsulosin 0.4 mg PO daily

Allergies:

• Denies any food, medication, or environmental allergies.

Social history:

• Married, lives on second floor of apartment.
• Retired. Able to perform all activities of daily living independently with no assistive devices.
• Habits: Denies present or past tobacco use, alcohol use or illicit drug use.
• Recent travel: Denies
• Diet: Healthy diet  
• Exercise: Denies exercising.
• Sleep: Reports sleeping eight hours a night.
• Sexual history: Denies being currently sexually active
• Urologist:

Vaccinations:

• Received two doses of COVID-19 vaccine
• Influenza vaccine in 09/2021
• Pneumococcal vaccine UTD

Review of Systems: 

General: Admits to weakness. Denies fever, chills, fatigue, night sweats, decreased appetite, weight gain/weight loss.

Skin, hair, nails: Denies changes in texture, discoloration, excessive dryness or sweating, pruritis or changes in hair distribution.

Head: Denies current headache or head trauma. 

Eyes: Denies blurry vision, double vision, loss of vision, photophobia, pruritus, or lacrimation.

Ears: Denies hearing loss, discharge, tinnitus, ear pain or use of hearing aids.

Nose/Sinuses: Denies nasal congestion, nasal discharge, sinus pressure/pain, or loss of smell.

Mouth/throat: Denies bleeding gums, mouth ulcers, sore throat, voice changes or use of dentures. Last dental exam unknown.

Neck: Denies localized swelling/lumps, pain or stiffness/decreased range of motion.

Respiratory: Denies shortness of breath, cough, wheezing, sputum production. 

Cardiovascular: Admits to syncope. Denies palpitations, chest pain, leg edema, irregular heartbeat or known heart murmur. 

Gastrointestinal: Denies abdominal pain, abdominal distention, nausea, vomiting, hematemesis, diarrhea, constipation, hemorrhoids, rectal bleeding.

Genitourinary: Denies dysuria, hematuria, hesitancy, flank pain, nocturia, oliguria, polyuria, frequency, urgency, incontinence.

Musculoskeletal: Admits to right shoulder pain. Denies any other muscle or joint pain, back pain, redness, stiffness, or deformities.

Peripheral vascular: Denies intermittent claudication, peripheral edema, coldness or trophic changes, varicose veins, or color changes.

Hematologic: Denies anemia, easy bruising or bleeding, lymph node enlargement, blood transfusions or a history of DVT/PE.

Neurologic: Admits to LOC. Denies lightheadedness, dizziness, headaches, sensory disturbances, changes in cognition/memory or numbness.

Psychiatric/Behavioral: Denies sleep disturbance, depression, suicidal ideations or seeing a mental health professional.

Physical Exam: 

VS: T 98.8 F, BP 169/92, HR 52 bpm, RR 16 unlabored, O2 sat 96% on room air, Ht 5’10”, Wt 143 lbs, BMI 20.5

Gen: Awake, alert, and oriented to person, place, and time. Well-appearing. Lying in bed in no acute distress.

Skin: Xerosis. Abrasion to right shoulder. No rash, bruises, or pallor. Non-icteric skin.

Head: Normocephalic, atraumatic.

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

ENT: Mucous membranes moist. No erythema or exudates in oropharynx. Uvula midline. Neck: Trachea midline, thyroid non-enlarged. No lymphadenopathy. Full range of motion. No carotid bruits. No JVD.

Cardiovascular: Bradycardic. Regular rhythm. S1 and S2 with no murmurs. 

Respiratory: Lungs clear to auscultation bilaterally. No wheezing, rales, or rhonchi. No accessory muscle use.

Abdomen: No scars, ecchymosis, or abnormal pulsations. Bowel sounds present in all quadrants. Soft, nontender, nondistended with no rebound or guarding. No CVAT,

GU: Foley to leg bag in place on right leg.

Extremities: No ecchymosis, atrophy, gross deformities, or edema. Full range of motion of all extremities. No tenderness to bilateral shoulders. Radial pulses, DP/PT pulses 2+ bilaterally. Capillary refill less than 2 seconds bilaterally.

Neuro: No focal neuro deficits. CN II-XII grossly intact.

Differentials:

• Syncope secondary to urinary tract infection
• Syncope secondary to cardiogenic cause
  • Symptomatic bradycardia
  • Arrhythmia
  • Aortic stenosis
• Orthostatic syncope

Labs:

• CBC
  • WBC: 29.42
  • RBC:4.53
  • Hemoglobin: 9.9
  • Hematocrit: 33.4
  • MCV: 33.4
  • MCH:  73.7
  • MCHC: 21.9
  • RCDW: 15.6
  • Platelets: 210
  • Segmented Neutrophils %: 16
  • Lymphocytes %: 79.00
  • Monocytes %: 4.00
  • Eosinophils %: 1.00
• BMP   
  • Sodium: 143
  • Potassium: 4.8
  • Chloride: 109
  • Carbon dioxide: 20
  • BUN: 20.7
  • Creatinine: 1.81
  • Glucose: 188
  • Anion gap: 14
  • Calcium level total: 8.8
  • BUN/Creatinine ratio: 11
• Lower GFR: 36
• Higher GFR: 41
• Live function panel
  • Alkaline phosphatase: 82
  • AST: 19
  • ALT: 17
  • Protein total: 6.6
  • Albumin:4.3
  • Globulin: 2.3
  • Bilirubin: 0.3
  • Direct bilirubin: 0.1
  • Indirect bilirubin: 0.2
• APTT: 27.8
• Prothrombin time: 11.0
• INR: 0.96
• Troponin    <0.010  

• Urinalysis
  • Color: Yellow
  • Appearance: Cloudy
  • Glucose: negative
  • Bilirubin: negative
  • Ketones: trace
  • Nitrites: negative
  • Leukocyte esterase: large
  • Bacteria: positive
  • Gravity: 1.017
  • WBC: >100
  • RBC: 48
  • Squamous epithelial cells: 0
  • Hyaline cast: 0
  • Blood: Moderate  
  • pH: 5.5
  • Protein: 100
  • Urobilinogen: 0.2
  • Yeast: Present

• SARS-CoV-2-NAAT: negative

EKG:

• Sinus bradycardia at 48 bpm, no ST elevations, or depressions. Unchanged from prior EKG 9/2/21.

Imaging:

• CXR: No focal consolidations or pleural effusions
• XR right shoulder: No evidence of acute displaced fracture or dislocation
• CT head w/o contrast: No evidence of acute intracranial abnormality

Assessment/Plan: 

75 y/o M with PMHx of HTN, BPH with foley and recurrent UTIs, who presented to the ED s/p a syncopal episode. Patient was afebrile and bradycardic to the 50s with regular rhythm and foley to leg bag.  Labs significant for leukocytosis of 29k and H/H 9.9/33.4. CXR, XR right shoulder and CT head all negative. Patient received fluids, Td vaccine and Ceftriaxone and will be admitted to medicine for syncope workup.  

Syncope likely secondary to urinary tract infection:  

• UA positive
• Replace foley catheter
• Follow up urine culture, previous grew E. coli
• Ceftriaxone 1g administered
• Urology consult

Bradycardia:

• Admit with telemetry
• First troponin negative, trend
• TTE
• Carotid ultrasound
• Orthostatics
• Cardiology consult

Right Shoulder Abrasion:

• Bacitracin applied to right shoulder

AKI on CKD:

• Ordered urine electrolytes
• Monitor creatinine
• Renal consult
• Avoid nephrotoxic medications

? Leukemia history:  

• Heme/onc consult

Anemia:

• Monitor H/H
• Ordered anemia panel: Iron, TIBC, Ferritin, Folate and B12

Hypertension:

• Continue with home medications Amlodipine and Hydralazine
• Hold home medication Losartan secondary to AKI versus CKD
• Holding parameters: HR less than 50 bpm, systolic BP less than 100

BPH:

• Continue with home medication Tamsulosin

DVT prophylaxis:

• Venodynes

Diet:  

• Renal diet