12/25, 02:00 Admission H&P:

Identification: Mr. S. Claus is a 2000 y.o. Nordic male BIBS (Brought In By Sled) after being found down in Yule.

History of Present Illness: Patient is undocumented and new to this hospital system, having previously received care at NPMG (North Pole Medical Group) prior to losing his insurance due to his seasonal employment status. Records unobtainable due to non-interoperable EMR system (EPIC: Elvish Polar Information Cache). History obtained via AT&T Elvish translator.

Apparently patient was in his usual state of chronic disease until the Night Before Christmas, when he was found down by a local family at the bottom of their fireplace. EMS and firefighters were called to extract him, but he was found to be quite agitated and combative, vomiting egg nog-tinged coffee grounds into a red stocking hanging on the fireplace. After 15mg of haldol and 7.5 mg Ativan in the field he was finally subdued and rushed to the ER with full jingle bell sirens. Several reindeer presumed to be his were tranquilized at the scene by animal control authorities and will be quarantined for further testing (a bystander has already filed several complaints on social media, claiming to have contracted “Chronic Lyme Disease”). Partially-consumed cookies were found by the chimney and paramedics report a fingerstick glucose of 1836 in the field.

In the ED he is found to be an extremely poor historian, answering most questions inappropriately with “Ho Ho Ho!” followed by paroxysms of wheezing.

No family contacts are available, although his wallet contains a picture of what appears to be an obese, rather hirsute male, labeled only “Mrs. Claus.”

He denies chest pain, dizziness, rectal bleeding, and his own existence. Please see detailed med student note for further useless history.

ROS: Unable to obtain as pt responds only with, “You are on the naughty list, little boy!” and subsequently vomits bright red blood and chunks of figgy pudding.

Allergies: Tylenol, codeine, “all that stuff that doesn’t start with a D”, saline, O2

Past Medical History: Sleep Apnea noncompliant with CPAP, Coronary Artery Disease, Diabetes Mellitus Type II, Congestive Heart Failure (diastolic dysfunction), Chronic Hepatitis C, Intractable Erectile Dysfunction, Gout.

Meds: Mistletoe 2 sprigs q6hrs, Fruitcake 1 loaf daily, Figgy Pudding QHS PRN angst, Oxycontin 80 mg BID, Viagra.

Social History: Married, self-employed as a toy deliveryman. Denies tobacco, but CAGE questions positive for likely egg nog abuse and candy-cane huffing.

Family History: Adopted by elves.

Physical Exam: VS Temp: 87.6F BP: 290/palp Pulse: 240 irreg irreg O2 sat: 74% on 14L (BIPAP not possible secondary to beard) PAIN SCORE: 17/12

BMI 40+ Appears older than stated age.

Morbidly obese, inappropriately jolly man in remarkably mild distress

Obvious rhinophyma, poor dentition, breath smells of mistletoe and acetone

Diffuse wheezes bilaterally with “wrapping paper” rales at the bases

Heart is enlarged with displaced PMI, “Jingle Bells” murmur at the apex

Abdomen is obese, benign with well-healed Christmas-tree shaped scar. “Tinkling” bowel sounds.

Extremities show 3+ pitting edema to the thighs with holly-shaped rash on shins

Neuro: “Stocking” pattern neuropathy of feet/legs

Rectal exam: + yule log

Genitourinary: soot-covered testicles. Santa’s tree is untrimmed.

Studies:

ECG: rapid atrial fibrillation with Osborn waves

Impression:

Elderly undocumented Nordic male with acute on chronic everything.

Acute Egg Nog Intoxication with Psychosis. Lipoid aspiration pneumonia. Likely Salmonella. Subsequent episode, W32.4AD Suspected Borderline Personality Disorder (views children as either all good or all bad). Prior records suggest “doctor shopping” and mistletoe-seeking behavior. Chronic Obstructive Pulmonary Disease secondary to longstanding chimney smoke exposure, with likely additional component of fibrosis and restriction — “St. Nick’s Triad” Obesity Hypoventilation Syndrome, complicated by non-compliance with CPAP and lack of available power outlets in his sled, and further worsened by fixed belief in “alternative” medical treatments such as candy cane extract and elf-magic. Possible Lyme Disease secondary to reindeer tick exposure. Deep Venous Thrombosis with risk factor of prolonged air travel, obesity, trauma from recurrent chimney intrusion, Christmas Factor overproduction. Atrial Fibrillation: “Holiday Heart.” Chronic Testicular Inflammation secondary to chimney soot-induced dermatitis, W29.3DX Jingle Balls, Acute, Bilateral, Initial episode Syndrome X(mas): insulin resistance, hypertension, central obesity, and elevated triglycerides that occur in conjunction with an epidemic retail Christmas decoration outbreak, occurring earlier and earlier every year (symptoms now start as early as the day after Halloween). Diabetic hyperosmolar state with dehydration secondary to cookie ingestion End-stage gout.

Plan:

1. Ho Ho Hospice.

Total 70 minutes floor time, >50% coordination and counseling.

Until next time, merry Christmas to all, and to all a good call night!

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