Problem:
Upon arrival on the unit, the attending on call physician conducted an assessment of the patient, who was found to be heavily sedated du medications that were administered late at 1047pm following patient request, patient was noted with a blunted pain response and uncooperative, preferring to rest. A wheelchair with 1:1 assistance was ordered, along with hydration, vital sign monitoring, and an EKG scheduled for the next morning, to hold medications further evaluation until evaluated by ward MD. The attending on call physician recommended the patient be evaluated by Physical Therapy in the morning when he would be more responsive, and to assess for pain, range of motion, and send for X-ray if significant findings. The MD assessment also suspected mail ankle sprain as no ankle swelling or deformity evident at the time of assessment. The MD indicated he would give report to the Unit ward Medical Specialist at 8:30 in morning of 6/8/26 for continuity of care. Upon arrival in the morning, the Medical Specialist assessed the patient in the presence of staff, during which the patient reported a pain level of 6/10 in the right ankle upon movement and described feeling lightheaded and dizzy during the fall. The patient remained alert without loss of consciousness but was unable to bear weight on the right foot due to pain. Examination revealed swelling and tenderness above the right ankle with limited range of motion, though no tenderness was noted in the foot or toes. The patient was diagnosed with right ankle and lower leg pain following the fall, as well as bradycardia during the incident. Subsequently, the patient was transferred to Long Island Jewish Hospital for further evaluation to rule out any bone injuries and arrhythmias. Triage details were conveyed to the nurse in charge, and the patient opted to decline family contact, stating he would reach out himself. Follow-up discussions regarding the case were held with the treatment team.
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