Patient Note (Jimmie)
Jimmie
(Patient ID 025)
| Name: Jimmie | Age: 79 | Admit date: 3.5 weeks ago | MR #: 000-025 |
| Gender Identity: Female | Race: Caucasian |
Admitting diagnosis: Left hip fx s/p CRPP |
Insurance: |
| History of present illness: Jimmie is a 79-year-old woman who suffered a left femoral neck non-displaced fracture after a fall on black ice on her driveway. She underwent a closed reduction percutaneous pinning (CRPP) procedure 3.5 weeks ago. There was no complication post-operation. Post-op BP 96/58, on IV fluid. She was able to tolerate normal diet the next morning after surgery and BP 115/70. She was taking Percocet 5mg q6 PRN for pain control. She was being monitored on post-surgical floor for 3 days and received acute physical and occupational therapy evaluation and plans. She was transferred to a skilled nursing facility that is close to her daughter 3 weeks ago. | |
| Past medical/surgical history: Hypothyroidism, syncope, mitral valve replacement |
| Social History: Jimmie lives alone in a single-family house where she has been living for 55 years since she was married. She and her husband raised three children in this house. Her husband passed away 4 years ago with complications after a stroke. Jimmie wants to stay living in this house as long as she can. | |
| Employment/work/school: Retired | |
| Prior level of function: Prior to the fall incident, Jimmie was independent in all ADL and IADL. Since the passing of her husband, she tends to make only simple meals. She occasionally experiences fatigue and tries to plan her day and activities carefully. Her daughter suggested hiring housekeeping for her, but she does not like the idea of having a stranger coming to the house, and wants to do it by herself as long as she can. | |
| Living situation/environmental barriers: There is one step to enter the house. Living room, dining area, kitchen and a powder room (without bath) is on the main floor. There are 12 steps to the second floor, with railing on the left. Jimmie’s bedroom is attached to a full-bathroom on the second floor. |
Fall precautions
May ambulate if BP is above 110/70
levothyroxine
aspirin
hydrochlorothiazide
acetaminophen as needed
| Result | Reference Range | Today | Date | Date | Date |
| Calcium | 8.6-10.3 mg/dL | 9.2 | |||
| Chloride | 99-108 mEq/L | 99 | |||
| Glucose | 70-100 mg/dL | 82 | |||
| Potassium | 3.7-5.1 mEq/L | 3.7 | |||
| Sodium | 134-142 mEq/L | 138 | |||
| BUN | 6-25 mg/dL | 15 | |||
| Creatinine | 0.7-1.3 mg/dL | 0.9 | |||
| Magnesium | 1.2-1.9 mEq/L | 1.4 | |||
| Total protein | 6.4-8.3 g/L | 6.6 | |||
| Albumin | 3.2-4.8 g/L | 3.5 | |||
| Hemoglobin | 14-17.4 g/dL | 15 | |||
| Hematocrit | 42-52% | 46 | |||
| WBC | 5.0-10.0 109 | 8.3 | |||
| Platelets | 140-400 k/uL | 175 | |||
| INR | 2.0-2.5 (stroke) | 2.2 | |||
| T4 count |
Disclaimer: Although the individuals in ICE videos are real patients, the exact history has been altered to protect their identities.