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MV 64 yo female lives alone NKDA - Coggle Diagram
MV
64 yo
female
lives alone
NKDA
found by family on floor
down for 4-5 hrs
pt reported slipped off bed
no injuries
arrival to RCH by EHS
subtle L sided deficits (new)
bilateral shoulder pain
full code
ROS/differentials
query: CVA?
GCS, LOC, NVS
Priority problems: increased ICP, changes in GCS/LOC, aspiration, pain, LB/aphasia?
maintain HOB elevated, monitor BP & NVS q15, safety equipment/check,
query: polymyalgia rheumatica
query: statin induced myalgia
CT angio: no arterial occlusions, ventriculomegaly
atrophy & obstructive hydrocephalus
neurology to follow up, lumbar puncture may be needed
MRI head: diffuse cerebral atrophy
Thyroid U/S: bilateral thyroid nodules
fine needle aspiration
complete as outpatient (to be booked before D/C)
bipolar type 1
early onset dementia
T2D
Elevated cholesterol
rectal polyp (2018)
immunized Moderna x2
Daughter as main caregiver
LB: only speaks Serbian
Previous Dx
Schizoaffective disorder
last admission 2015 for 2 months
in process to set up home health