Weakness and Fall

Progress Report

Patient: 86-year-old male
PMHx: COPD, CAD, HTN, AAA with type 2 endoleak of aortic graft, bladder cancer on active immunotherapy, HFpEF, moderate aortic regurgitation

Presentation: Fall, associated weakness

Hospital Course & Workup

Patient presented following a fall. Multiple imaging studies were performed and revealed no significant musculoskeletal injuries. Current focus is on evaluating the cause of his fall and subsequent weakness.

Troponin was elevated but stable, consistent with myocardial injury (Type 2 NSTEMI). Echocardiogram was ordered to assess for potential worsening of moderate aortic regurgitation. Telemetry initiated to monitor for arrhythmias given patient’s extensive cardiac history.

Orthostatic vitals were negative from lying to sitting; plan to repeat tomorrow with sitting to standing, in coordination with PT. PT has recommended rehabilitation, but insurance coverage appears to be a barrier.

Assessment & Plan

# Weakness and Fall

• Workup ongoing.

• Orthostatics negative (lying → sitting); repeat with sitting → standing.

• PT recommends rehab; insurance barrier noted.

# HFpEF

• Continue: metoprolol, furosemide, empagliflozin, spironolactone.

• Cardiac diet, nutrition supplements.

• Echo pending to reassess EF and aortic regurgitation.

# Aortic Regurgitation

• Monitor via echocardiography.

• No acute decompensation noted at this time.

# Myocardial Injury (Type 2 NSTEMI)

• Elevated but stable troponins.

• Continue aspirin and rosuvastatin.

• On telemetry for arrhythmia monitoring.

# Bladder Cancer (on active immunotherapy)

• Continue chronic prednisone.

# Asymptomatic Bacteriuria

• Completed 3 doses of ceftriaxone.

• Urine culture: mixed flora.

• No further antibiotics indicated.

Comorbidities Present on Admission

• Chronic Heart Failure with preserved EF (last EF: 66%, 4/25/25)

• Thrombocytopenia

• Immunosuppressed (immunotherapy + prednisone)

• Hypercoagulable state (history of atrial fibrillation)

Secondary Diagnoses During Hospitalization

• Hyponatremia

• Thrombocytopenia (persistent)

• Elevated troponin (Type 2 NSTEMI)

Current Medications

• Empagliflozin

• Famotidine

• Furosemide

• Metoprolol succinate XL

• Prednisone

• Rosuvastatin

• Spironolactone

VTE Prophylaxis

• Enoxaparin (Lovenox) 40 mg subQ daily

Diet

• Cardiac diet

• Nutrition supplements

Discharge Planning

• AM-PAC (RN/PT): 7 / 7

• PT Disposition Recommendation: Moderate complexity (09/26/25)

• Expected Discharge Location: Unclear

• Barriers: Completion of fall/weakness workup, rehab insurance coverage

• Code Status: Full Code

Nursing Note

Patient is alert and oriented ×3, on room air without shortness of breath. Hearing impairment noted. Denies pain or discomfort. Vital signs stable. Safety measures intact. Care plans reviewed and patient verbalized understanding.