DATE OF ADMISSION: MM/DD/YYYY
CHIEF COMPLAINT: Arthritis.
HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old patient with arthritis in her hips and in her shoulders. She states it is getting progressively worse. She has been placed on diclofenac. She states that she can hardly walk today as a result of it. She is supposed to see Dr. John Doe for this as well and is unsure whether something surgical will be done. The patient complains of a 10/10 pain, worse when she tries to walk. She lives by herself. Nursing notes were reviewed.
PAST MEDICAL AND SURGICAL HISTORY: Hip and knee replacement, arthritis, IDDM, and left shoulder arthritis scheduled for surgery.
MEDICATIONS:
1. Zoloft.
2. Actos.
3. Bumetanide.
4. Diclofenac.
5. Vytorin.
ALLERGIES: Sulfa.
SOCIAL HISTORY: The patient denies any smoking history and lives alone.
FAMILY HISTORY: Noncontributory.
IMMUNIZATIONS: Noncontributory.
REVIEW OF SYSTEMS: Negative for any fevers, chills, chest pain, shortness of breath, cough, headache, weight loss or weight gain, dysuria, urinary frequency, or rash. The remainder of review of systems reviewed was negative.
PHYSICAL EXAMINATION:
GENERAL: The patient is obese and nontoxic.
VITAL SIGNS: Temperature 98.2, pulse 82, respirations 20, blood pressure 138/70, and room air pulse ox 99%. It is within normal limits.
HEENT: Nonicteric sclerae. PERRLA. EOMI.
CHEST: Chest wall nontender.
LUNGS: Clear to auscultation bilaterally.
HEART: Regular rate and rhythm.
ABDOMEN: Soft, positive bowel sounds, nontender, no organomegaly.
EXTREMITIES: Reveal bilateral hip tenderness. There is tenderness on palpation diffusely over the left shoulder without obvious deformity, and distal neurovascular as well as tendon status intact.
NEUROLOGIC: No gross motor or sensory deficit. Reflexes 1+ and equal.
DIAGNOSTIC DATA: X-ray, two views, interpreted by the radiologist, shows no acute bony abnormality; previous left total hip replacement; moderate DJD, right hip; 12 mm lucency inferior to medial to right pelvic ramus.
EMERGENCY DEPARTMENT COURSE: The patient was given pain medicine here. The patient is still not able to ambulate; although, the pain feels better.
PROCEDURES PERFORMED: None.
MEDICAL DECISION MAKING: We do not think we are dealing with entities that include, but not limited to, any kind of acute fracture, septic joint, or stroke. We think this individual is dealing with intractable pain from her arthritis. At this point, she is unable to care for herself and will need to be brought in for further pain treatment and management, as well as possible placement into a rehabilitative facility. The patient is unable to care for herself at this time or walk. She is a fall risk, particularly with her added weight. With her shoulder injury hurting her so bad she cannot support herself much in the way of her upper extremities to use a walker.
IMPRESSION:
1. Intractable joint pain.
2. Inability to ambulate.
PLAN: The plan at this time is to admit the patient for further workup and treatment.
