Age: 88.0
Sex: M
Vaccine: COVID19
Symptoms: Dyspnoea, Haematoma, Haematuria, Peripheral swelling, Pulmonary embolism
Clinical narrative: SOCIAL SERVICES INITIAL ASSESSMENT   REFERRAL INFORMATION   Unit / specialty:   Referral for: Length of Stay   Referred by: Case-finding and Protocol   Information source / informant: Chart and Family: Pt's brother and sister in law   MEDICAL   Pertinent medical information: Pt is a 91 yr old male admitted on 10/29/23 for DIZZY, SHORTNESS OF BREATH   Pt's medical hx includes:  Past Medical History Active Ambulatory Problems   Diagnosis Date Noted ? ASTHMA WITH COPD 03/14/2001 ? GOUT 10/07/2000 ? HTN (HYPERTENSION) 09/15/2004 ? DIVERTICULOSIS OF COLON 06/20/2002 ? IRRITABLE BOWEL SYNDROME 06/10/1999 ? RENAL CALCULUS 01/20/2006 ? GERD (GASTROESOPHAGEAL REFLUX DISEASE) 03/04/2006 ? ALLERGIC RHINITIS 06/08/2007 ? SPINAL STENOSIS OF LUMBAR SPINE 06/08/2007 ? BASAL CELL CARCINOMA 02/10/2009 ? HYPERLIPIDEMIA 12/17/2009 ? HX OF RENAL CALCULUS 03/18/2013 ? ABNL DIGITAL RECTAL EXAM 03/18/2013 ? URINARY FREQUENCY 03/18/2013 ? NOCTURIA 03/18/2013 ? LOWER URINARY TRACT SYMPTOMS 03/18/2013 ? ADULT OBSTRUCTIVE SLEEP APNEA 04/13/2013 ? HX OF APPENDECTOMY 05/23/2013 ? HX OF COLONOSCOPY 05/31/2013 ? GENERALIZED ANXIETY DISORDER 09/27/2013 ? ATHEROSCLEROSIS OF AORTA 01/17/2014 ? MOOD DISORDER, UNSPECIFIED TYPE 06/09/2015 ? PRURITUS ANI 07/14/2015 ? BILAT CARPAL TUNNEL SYNDROME 08/20/2015 ? BPH (BENIGN PROSTATIC HYPERPLASIA) 04/30/2019 ? SYNCOPE 05/26/2019 ? LEFT ADRENAL MASS 09/02/2019 ? PULMONARY NODULE 02/27/2020 ? SPECIFIC PHOBIA, ENCLOSED SPACES 05/19/2020 ? SKIN MASS 02/08/2021 ? CHRONIC ABDOMINAL PAIN 02/08/2021 ? CAD (CORONARY ARTERY DISEASE) WO ANGINA 03/08/2021 ? LOCALIZED SWELLING ON RIGHT LEG 05/10/2021 ? URETERAL CALCULUS 12/15/2021 ? ELEVATED TROPONIN I 07/01/2023 ? GROSS HEMATURIA 07/02/2023 ? ACUTE PULMONARY EMBOLISM 07/03/2023 ? ACUTE DVT OF RIGHT FEMORAL VEIN 07/03/2023 ? HEMATOMA 08/14/2023 ? ANEMIA 08/14/2023 ? CHRONIC PULMONARY EMBOLISM 09/12/2023    Additional diagnoses from the Past Medical History section Diagnosis Date ? SEVERE OBESITY 1/17/2014      PRE-HOSPITAL LIVING ARRANGEMENT   Living arrangement (please specify name and contact info):  Alone   With community agency assist (please specify name and contact): Palliative   Baseline mental status: Unable to meet with pt at this time, pt Covid positive    Physical barriers in the home: Yes, pt lives alone    Provides care for another at home (please specify): No   PSYCHOSOCIAL STATUS   Orientation: Unable to assess, pt has Covid    Affect: congruency: Unable to assess, pt has Covid   Mood: Unable to assess, pt has Covid   Behavioral status: Unable to assess, pt has Covid   Psychiatric history: Yes (Please specify): Pt's sister in law reports pt has Depression and previously has taken medication for his depression    Suicidal risk: Unable to assess, pt has Covid   Substance abuse history: No   Substance use within last year: No   Have you been hit, hurt, harmed or threatened either physically, emotionally or financially? Unable to assess, pt has Covid   Special concerns during hospitalization: None   Work status: Retired   Is there anything specific that we should know regarding your cultural, personal, ethnic, or spiritual preferences that would help us care for you? Yes (Please specify): Pt's brother reports pt identifies as religious   Patient is at risk for psychosocial complications which may impact recovery or treatment: Unable to assess, pt has Covid   Patient's perception of situation/issue/illness: Unable to assess, pt has Covid   Family's perception of situation/issue/illness: Pt's brother and sister in law aware of pt's situation and don't feel pt is able to go back home, may be considering board and care or hire caregivers    End-of-life issues: No   Ability to perform roles in home, school, work, and social activities (age appropriate): Adult: Pt's PLOF was independent with ADLS.Does not drive (grandson or friend for transportation)  ambulatory and uses FWW within household distance   According to pt his friend comes twice a day daily. His friend prepares his breakfast and dinner. His grandson or his friend gets his grocery. Pt states he pays his friend for the assistance he receives.    Social support: Yes: Pt's social supports include his friend, brother and sister in law who live in another city, grandson, and granddaughter   Psychosocial barriers in the home: No   Strengths in family: Pt has support of brother/DDM and sister in law    Problems in family: None reported   Body image: N/A   Behavior and coping effective to situation - consider cultural, spiritual, and emotional factors: Unable to assess, pt has Covid   Educational and community resources: Yes: MSW provided pt's ssiter in law and brother via email with a a list of County resources that includes medication co-pay aid and financial assistance, food assistance, applying for public assistance, housing and bill assistance, AD, free aid-low income, legal advocates and ombudsman, IPV victim support, transportation, mental health, substance use support, home care agencies/caregiver resources, placement agencies, senior services, veteran services, medical alert systems, medical equipment and supplies. MSW explained this is an out of pocket cost if they decide to hire caregivers or have pt go to board and care.      Agency eligible:Not assessed        LEGAL/ORGANIZATIONAL ISSUES   Significant problems with organizations: No   Completed Advanced Health Care Directives: Yes (Please specify): AHCD on file 9/6/18 pt's brother listed as DDM    Patient has pre-hospitalization DNR: Yes: Per chart, 11/6/23   General legal issues: None   Suspected child, elder, domestic abuse/neglect:  Unable to assess, pt has Covid   Legally mandated report required: No   Patient reqeusts discharge planning/PHI to be discussed with: Pt's brother   Patient requests planning NOT to be discussed with: N/A   FINANCIAL   Sources of income: Income   Insurance coverage (including long term care)  Pt has Payor:      Medi-Cal eligible:  Not assessed    IMPRESSION/PLAN   DME Needed/Recommended: Please refer to notes   Impression: Assessment Summary:  MSW chart reviewed. MSW unable to meet with pt at bedside due to pt having Covid. MSW called pt's brother/DDM. MSW introduced self, role, and purpose of phone call. Pt's sister in law answered as pt's brother was driving and they report they are on their way to visit pt now. MSW provided pt's sister in law and brother with County Community resource packet that includes caregiver resources and board and care resources. MSW explained this is an out of pocket cost if they decide to hire caregivers or have pt go to board and care. MSW provided social services contact info.    ANTICIPATED DISCHARGE PLAN TBD pending clinical status   Patient and family (or surrogate) agree with plan: DC plan pending still according to pt's chart and family   11/6/2023 12:24 PM       Note Details  Author File Time 11/6/2023 12:24 PM Author Type (none) Status Signed Last Editor Service (none) Hospital Acct # Admit Date 10/28/2023  ED to Hosp-Admission (Current) on 10/28/2023  ED to Hosp-Admission (Current) on 10/28/2023   Detailed Report  Note shared with patient Care Timeline  10/29   Admitted from ED (Observation) 0118    Admitted 1054  PT in house Bed