Question Answered step-by-step Patient Information: L.J. 82, Male, African American S.CC Fall at homeHPI: Patient is an African American male, 82 years old. With past medical history of hypertension, dementia, and a previous fall at home. Patient was found unresponsive on the floor of his home by his son who called the ambulance. The patient’s wife thinks the patient fell a few steps down the stairs from the second floor. The event was not witnessed. The paramedics report the patient was alert and awake he was oriented to person, he was able to state his name, but he was not able to state his date of birth or the year, he was confused about the place and situation. Patient was able to follow commands. He had no memory of what happen or the events involving his fall. The patient was sitting on the ground close to the stairs and was complaining of a pain on his right hip. When the paramedics tried to explore the characteristics of the pain the patient said he no longer had pain. He denied hitting his head, hip, or any part of his body. Patient was transported to the hospital for further evaluation. Patient was awake and alert during admission but confused. CT of head result showed bilateral acute on chronic subdural hematomas, 2cm right and 1 cm left. There is moderate volume loss. Current Medications: no current medicationsAllergies: none PMHx: Hypertension diagnosed several years ago; patient refuses to take medication to treat his hypertension. He was diagnosed with dementia three months ago when he was at the hospital for a previous fall that resulted in a subdural hematoma affecting the left side of his brain that required medical management only, no surgery was needed. He was discharged home with no deficits. Patient has no adult immunization no pneumonia, flu or COVID 19 immunization. The rest of his family is fully vaccinated against COVID, but the patient refused to take the vaccine. No surgical historySoc and Substance Hx: Patient lives with his wife, his son and one grandson. His wife states the patient has no history of smoking or drug abuse, but he started drinking alcohol 2 years ago. He drinks three glasses of wine every day. His family thinks that he had the fall because he was highly intoxicated. During his previous fall, his alcohol level was high. Patient is a retired pastor. He spent more than 40 years before he retired but he was an active member of his congregation and continued to participate and run programs in his community. He stopped participating with his community 2-3 years ago at the same time he started drinking. He was highly active and healthy no problems with his weight, but he never attended any clinic or wellness program. He was able to perform activities of daily living and driving. The only change that they noticed was during the last week, he started having problems with his gait and was unsteady. He uses his seat belt. They have smoke detectors at home and his son changes the batteries regularly. Patient lives on the first floor of the house but the kitchen and living room are on the second floor.Fam Hx: mother died of diabetes, father died of pneumonia, his wife cannot recall about the grandparents, the patient has 4 sisters and 3 brothers. He has three siblings that died. One sister of lung cancer, one sister giving birth and one brother in a car accident.Surgical Hx: Prior surgical procedures.Mental Hx: Wife denies any previous mental history, no depression, no anxiety. Violence Hx: no history of family violenceReproductive Hx: no sexual concernsROS: GENERAL: denies weight loss, chills, fever, fatigue, shortness of breath, chest pain or palpitations. HEENT: Eyes denies visual changes, wears glasses to read no corrective glasses. Some teeth are missing, he has his own teeth. No rhinitis, sinusitis, or epistaxis. No secretions, some hearing loss was prescribed hearing aid, but he is not using it. SKIN: denies any rash or alterations. CARDIOVASCULAR: denies chest pain, shortness of breath, no orthopnea to sleep, no palpitations, no edema on extremities.RESPIRATORY: No shortness of breath, no rhinitis, no sinusitis, no allergies, or asthma. GASTROINTESTINAL: denies nausea, vomiting, diarrhea, denies constipation, abdominal pain, blood in stools. Patient is continent. GENITOURINARY: Patient is continent walks to the restroom, denies any pain during urination. No changes in urine patterns. NEUROLOGICAL: patient is awake and alert. He is alert to person only. Denies headache, dizziness, numbness on extremities. MUSCULOSKELETAL: no joint or muscle pain, denies stiffness. HEMATOLOGIC: no bruises, or bleeding, denies anemia.LYMPHATICS: denies any enlarged nodes, no edema on extremities, no splenectomy.PSYCHIATRIC: denies anxiety, depression, or mental diseaseENDOCRINOLOGIC: denies diabetes, no sweating or heat intolerance. Denies polyphagia, polyuria, or polydipsia. ALLERGIES: denies history or asthma, rhinitis, eczema, rash, no seasonal allergies, no sneezing O. The physical exam reveals.VS Pulse Ox 99% on room air B/P 148/89 Temp 98.5 Pulse 71General appearance patient is not in acute distress, drowsy but arouse easily.Head normocephalic, atraumatic, no bruises or bumps noted, no missing tissue or road rash.Eye pupils are equal reactive to light 3mm bilateral.Nose pink, no drainage noted.Oral mucosa dry, some teeth missing.Neck no masses noted, trachea midline, no JVD.Cardiovascular chest area symmetric, regular rate and rhythm, pulses present on extremities, no edema on extremities.Respiratory symmetric lung area, atraumatic, clear to auscultation, no crepitus or tendernessAbdomen flat, no tender no organomegaly noted, bowel sounds present. Back atraumatic, no midline vertebral tend, no CVA tenderness.Pelvis stable, no tenderness Extremities, no deformity, intact no edema, no tendernessSkin paper thin, dry, no woundsGlasgow coma scaleEye opening to sound 3.Verbal response confused 4.Best motor response follows commands 6.Total score 13Neuro alert and awake oriented to person, follows commands, moves all extremities no deficits. Patient is confused about the place, time, and situation. Patient has episodes where he is totally confused does not follow commands tries to get out of the bed with no assistance. Episodes last minutes to hours patient gets agitated, combative, aggressive, pulling lines, and physical or verbal abusive of staff and family members.Diagnostics ResultsChemistrySodium 141 potassium 3.6 chloride 103, carbon dioxide 26, anion gap 15, BUN 10, creatinine 0.6, glucose 76, total bilirubin 0.70, AST 34, ALT 10, Total ALK Phosphatase 43, total protein, 6.5, INR 1.3, PTT 29.7, PT 14,3 magnesium 2.0Hematology WBC 6.8 Hgb 11.0 Hct 34.5 PLT 214 SARS-CoV-2 Ag negativeToxicologyAlcohol 160.6CT bilateral acute on chronic subdural hematoma, 2 cm right and 1 cm left, there is moderate volume loss.Diagnosis 1.- Acute subdural hematomaCT positive for acute and chronic subdural hematoma2.- Dementia Mini Mental State Examination was performed score was 18 moderate degree impairment 3.- Alcohol intoxicationToxicology alcohol level 160.64.- He has history of hypertension no on medication.Differential diagnosesStrokeCT was positive for subdural hematoma with history of head injury. DepressionDepression cannot be ruled out at this time due to acute injury and confusion. Patient needs to be assessed when his clinical condition improves. Depression can be a symptom of dementia. SeizuresThe patient had a no witnessed fall.Plan1.-Acute subdural hematomaMaintain patient on the neuro trauma ICU unit.NPO until speech pathologist evaluates the patient.Neuro check every 2 hours while in the ICU.Maintain SBD 100-150Maintain Sodium level above 140.Maintain Mg 1.8-2.4No antiplatelets or anticoagulants Head of the bed elevatedMaintain the room quiet and dark to avoid overstimulation.Patient was referred to neurosurgery for surgical evaluation. They recommended medical treatment only, no surgery because there was no midline shift and no herniation in the results of the CT of the head.Speech pathologists consult for evaluation of cognitive degree and swallow abilities.Physical/Occupational therapist evaluation to work on strength and bed mobility. Rehabilitation evaluation to consider admission to inpatient rehabilitation program.Patient needs referral with case manager for skill facility or rehabilitation placement.2.- Dementia Pharmacological treatment includes.Memantine, rivastigmine, galantamine, and donepezilBehavioral symptoms of dementia include depression, anxiety, irritability. Antidepressants SSRI, anxiolytics and antipsychotics can help on reducing the symptoms. Family counseling and referral to social serviceSupport groups are helpful.Driving restrictions 3.- Alcohol Intoxication ThiamineFolic acidHaloperidolCIWA protocolCounseling on alcohol cessation Seizure precautionsReflectionThis case was challenging to manage due to the complexity of the situation. The patient was admitted after a fall at home with elevated alcohol levels. The family said the patient was independent. He could drive and perform activities of daily living. Something that I would do different is request more information to clarify the cognitive level of this patient. The patient’s memory and cognitive level seems more limited in comparison of what his family perceives. Health promotionThe patient is no longer able to make his own decisions. His wife will be making decision on his behalf. He needs further evaluation with his primary care provider to review the status of his immunization. Wellness checkup and referral to audiology to evaluation and replacement of hearing aid. He needs to resume hypertension medication. New Mini mental State Examination should be performed again when patient finish detoxication process and subdural hematoma is decreasing. Patient needs proper management of dementia and rehabilitation to return to family and church activities with his new level of function. His family is willing to participate on his care. What would be an appropriate discharge plan for this family and patient? 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