Virtual Morning Report Part 1

Features of the Case unrelated to the Diagnosis have been changed for patient privacy

60 yo F  Patient works in the IT department of Ford, recently retired

CC: ALTERED MENTAL STATUS

HPI: Patient went to work; clocked in at 7 AM on Feb 20, then clocked out at 7:30 AM, patient went to the car drove in the parking lot, then went back in clock in at 8 AM, then clocked at 8:30 AM went to her car and sat there. (Per security video footage) Patient remembers clocking in and out the first time but does not recall the second time.

Coworkers went looking for her, and had found her with her coat on, sitting in her car with it off and the windows up. They reported her saying ” I don’t feel like working”  They state she was found diaphoretic . Patient reported losing bladder control between 8 AM and 8:30. She said that “I felt like I needed to go on I went.” Patient talked to her daughter and she sent an ambulance to find her in the parking lot.

Past Medical History

Past Medical History GERD with Barrett’s esophagus, HTN, Obesity

Surgical History   Appendectomy, Cholecystectomy,

 Family History  Father: HTN, MI (@age 70) Dementia Mother: HTN,

Social History

    Never smoker

    Occasional Alcohol, 1-3 drinks/week

    Denies Ever: THC, LSH, IV drugs, etc.

MEDS: Omeprazole 20 mg PO Daily

Physical Exam

    Temperature:  98.8  Pulse:  91-107  Respiration:  17   BP:  188/85 on arrival, down to 123/61   Pulse Ox:  99 (RA)

Head: Normocephalic, atraumatic.  CV: Reg rate, ryth.  No LE edema.  No JVD.   Pulm: Lungs CTAB, no rhonchi, No inc work of breathing.  Abd: Soft, non tender, non distended.  Skin: No rashes, lesions or bruises. 

Neuro:

– Patient alert and oriented to person, place, time and situation. – Following simple and complex commands. – Naming and repetition intact  – No aphasia

– EOM intact. PERRLA.  No nystagmus.    – Face symmetrical – Shoulder shrug equal – Tongue midline – No dysarthria

Motor:  – RUE 5/5   – RLE 5/5  – LUE 5/5    – LLE 5/5   Sensation – Intact in all extremities Gait: No ataxia,

Psych: Patient is not responding to internal stimuli.  Mood is stable, appropriate, affect is somewhat flat.  Good eye contact.