H&P 1 LTC

Name: S.R

Sex: Male

DOB: xx/xx/1938

Date & Time: Sept 12, 2023, 1:00 pm

Location: St Albans VA

Religion: Unspecified

Source of Information: Self

Reliability: Reliable

Mode of transportation: Ambulette via Manhattan VA

Chief Complaint: “I fell” x 8 days ago.

History of Present Illness:

S.R is a 85 y/o non-smoker male ADL independent IADL dependent, ambulatory with walker at baseline with a PMH of HTN, HLD, CAD, NSTEMI, DES to LAD (1/12/16), CABG (11/2007), cardiac catheterization  (9/2012), carotid stenosis s/p CEA 7/2002, HFrEF (LVEF 40%), DM2, gout, osteoarthritis, glaucoma, BPH, chronic low back pain, depression, and diminished hearing  presented to Manhattan VA 8 days ago c/o a fall that occurred in his apartment unit while walking with his walker. Pt stated that after falling he could not get up due to severe lower back pain and due to not having “feeling” in his legs. His husband who lives with him then proceeded to call the ambulance. 

While at the hospital the patient received imaging studies via x ray which showed no acute bony abnormalities. The patient also received a CT of the head, neck, and spine, along with arterial and venous doppler studies of LE which showed no abnormalities as well. However, while at the hospital the patient’s oxygen saturation began to drop and was placed on a 3L nasal cannula, the patient had an elevated white count upon evaluation of his CBC. Chest x ray showed signs of a pneumonia and a CHF exacerbation. Treated with Augmentin and Lasix. Day 5, switched to azithromycin when culture grew Legionella. Pain was treated with oxycodone then switched to hydromorphone and Tylenol. Upon stabilization and clinical improvement patient was taken off the nasal cannula and was able to breath on room air. The patient was then transferred to the St. Albans VA facility for rehabilitation.

He reports a history of 2 previous falls in the past year and that he previously was able to ambulate with a walker, however since this most recent fall he feels as if he cannot walk at all. He admits to lower back pain that has been consistent in nature since his fall 8 days ago. The pain is in his mid-lumbar region with severity 7/10, sharp and non-radiating, accompanied by B/L numbness in all his toes with no alleviating or aggravating factors. Pt. also complains of persistent cough productive of yellowish-greenish sputum. Denies any urinary incontinence, headache, cognitive changes, joint swelling, fever, chills, SOB, or pain.

Later was informed by social work that patient requests to be discharged home today. Patient was then seen again in lobby area with his husband/healthcare proxy, who stated that he was in agreeance with the patient’s desire to be discharged home today. The husband/healthcare proxy stated that he lives with the patient and will be able to assist him at home, he also agreed to receive a home care referral. 

It was strongly recommended that the patient stay for a 1-week trial of rehab and repeat labs/medical monitoring at St Albans due to the patient’s weakness of his lower extremities and his productive cough with elevated WBC from his most recent CBC. However, the patient adamantly refused stating that he wants to be discharged home to the care of his husband and states he will follow up with his PCP at the Manhattan VA. 

Geriatric Assessment

• ADLs: Independent in all at baseline, however, is limited now due to symptoms.
• IADLs: Dependent in shopping, transportation, paying bills, preparing meals.
• Home Health Aide: None – patient states that he never got one because his husband takes care of him. The benefits and importance of having a home health aide were discussed and acknowledged by the patient. 
• Visual impairment: Yes – patient wears glasses; following with ophthalmology.
• Hearing impairment: Yes- patient has a hearing aid in his left ear and states he forgot the one for his right ear at home.
• Falls in the past year: 2 previous falls none of which required medical services according to the patient.
• Assistive devices used: Walker.
• Gait impairment: Yes – patient walks at slower speed (TUG test over 20 seconds)
• Urinary incontinence: None
• Fecal incontinence: None
• Osteoporosis: None
• Cognitive Impairment: None – Mini-cog: 5/5
• Depression: None – PHQ 9 completed, score 0/27
• Home safety issues: Patient home is neat and well kept, patient states his husband cleans daily. Home has good lighting and has bath rails present.
• Health Care Proxy: Yes – Husband J. R. (xxx-xxx-xxxx)
• Advance Directives: Full code

Past Medical History

Medical History:

• Hypertension (2000 – present)
• Type II Diabetes Mellitus (2001 – present)
• Hyperlipidemia (2001- present)
• Coronary artery disease (2002-present)
• NSTEMI (1/12/16)
• Carotid stenosis, treated with CEA (7/2002)
• Heart failure reduced ejection fraction to 40% (2002- present)
• Gout (2005-present)
• Osteoarthritis (2007-present)
• Glaucoma (2004-present)
• Benign prostatic hypertrophy (2004-present)
• Chronic low back pain (2005-present)
• Presbycusis (2010-present)
• Depression (2008- present)
• No history of blood transfusions.
• Immunizations up to date

Medications:

• Acetaminophen 1000 mg PO Q8H, for low back pain
• Amlodipine Besylate 5 mg PO QD, for hypertension
• Aspirin 81 mg PO QD, for coronary artery disease
• Atorvastatin 40 mg PO at night, for hyperlipidemia 
• Bupropion 150 mg PO Q12H, for depression
• Citalopram 10 mg PO QHS, for depression
• Clopidogrel 75 mg PO QD, for coronary artery disease
• Dorzolamide HCL 2% solution OPH 1 drop OU QD, for glaucoma 
• Empagliflozin 10 mg PO QD, for diabetes mellitus type 2
• Finasteride 5 mg PO QD, for benign prostatic hypertrophy 
• Furosemide 20 mg PO QD, for heart failure with reduced ejection fraction
• Latanoprost 0.005% 2.5 ML 1 drop OU QHS, for glaucoma 
• Losartan potassium 25 mg PO QD, for heart failure with reduced ejection fraction
• Metoprolol succinate 50 mg PO QD, for heart failure with reduced ejection fraction
• Tamsulosin 0.4 mg PO QD, for benign prostatic hypertrophy 
• Cyanocobalamin vitamin B12 1000 mcg PO QD
• Denies herbal supplement use.

Surgical History:

• Carotid endarterectomy, 7/2002, no complications, done at Manhattan VA
• Coronary artery bypass grafting, 11/2007, no complications, done at Manhattan VA
• Cardiac catheterization, 9/25/12, no complications, done at Manhattan VA
• Drug eluting stents placed to LAD post NSTEMI, 1/12/16, no complications, done at Manhattan VA

Allergies:

• No known drug/environmental/food allergies

Family History:

• Mother: Deceased age 87 from natural causes
• Father: history unknown.
• No known family history of cancer.

Social History:

• Smoking: Never
• Alcohol: Never
• Denies past or current illicit drug use.
• Marital History: Married to husband for the past 30 years.
• Language: Patient first language is Spanish, however can read and write and speak English
• Education: High school graduate 
• Occupational History: Retired, previously served in the army during the Vietnam war.
• Travel: No recent travel
• Home situation: Lives with Husband on 3^rd floor of apartment building with elevator. No carpets. Good lighting. Bathmat and bath rails present. 
• Sleep: Patient states he sleeps well about 8-9 hours per day.
• Exercise: Patient does not do exercise. 
• Diet:
  • Breakfast: eggs with toast and bacon
  • Lunch: a sandwich with turkey and cheese
  • Dinner:  mixed vegetables with chicken and pasta
• Caffeine: None
• Sexual history: Currently sexually active with his husband. No known history of STIs.

ROS:

• General:  Denies fatigue, fever, chills, night sweats, weight loss, and changes in appetite.
• Skin, hair, nails: Denies discolorations, moles, rashes, changes in hair distribution or texture, pruritus.
• HEENT: Denies head trauma, vertigo, visual disturbances, ear pain, hearing loss, tinnitus, epistaxis, discharge, congestion, sore throat, bleeding gums. Patient states last dental visit was 2 months ago. Last ophthalmology visit was 7 months ago.
• Neck: Denies localized swelling/lumps, stiffness/decreased ROM
• Pulmonary: Admits to cough with sputum. Denies dyspnea, wheezing, cyanosis, hemoptysis.
• Cardiovascular: Denies chest pain, edema/swelling of ankles or feet, palpitations.
• Gastrointestinal: Denies abdominal pain, nausea, vomiting, diarrhea, constipation, hematemesis, hematochezia, melena, intolerance to specific foods, anal bleeding. Last colonoscopy 10/18/2013, within normal limits.
• Genitourinary: Denies urgency, frequency, incontinence, hesitancy, dribbling.
• Musculoskeletal: See HPI
• Nervous system: See HPI
• Peripheral vascular: Denies intermittent claudication, varicose veins, coldness of extremities, color changes, peripheral edema.
• Hematologic: Denies easy bruising or bleeding, lymph node enlargement, history of DVT/PE.
• Endocrine: Denies polydipsia, polyphagia, heat or cold intolerance, excessive sweating.
• Psychiatric: Admits to h/o depression. Denies anxiety.

Physical Exam:

Vitals:

• Weight: 145 lbs. Height: 70 inches       BMI: 20.8 kg/m²
• BP: 120/67, left arm sitting. Repeat 126/72, right arm sitting.
• RR: 18, unlabored
• HR: 60, regular
• Temp: 98.0 F oral
• SpO2: 95% room air

General: 85 y/o male who appears stated age. Well-groomed. A/O x 3 and appears in no acute distress.

Skin: Warm, dry & intact. No rashes, cyanosis, moles, or lesions noted.

Head: Normocephalic & atraumatic

Eyes: Symmetrical OU. Sclera white, cornea and lens clear and conjunctiva pink. PERRL. EOM intact with no nystagmus.

Heart: Regular rate and rhythm. S1 & S2 distinct with no murmurs or gallops.

Chest: Symmetrical, no deformities. Non-tender to palpation. 

Lungs: Patient shows no signs of labored breathing or cyanosis. Respiratory rate is unremarkable at 18/minute with no neck or abdominal accessory muscle use. Lung expansion is symmetrical. Breathing noted with intermittent productive cough. Anterior and posterior chest walls have no tenderness, masses, or crepitus upon palpation. On auscultation expiratory wheezes are heard and scattered throughout all lung fields. Pulse oximetry 95% on room air. 

Abdominal: Abdomen symmetric and non-distended, with no striae or scars. Normoactive bowel sounds in all 4 quadrants. Non-tender to palpation and tympanic throughout with no guarding or rebound. No abdominal hernias noted. No CVA tenderness appreciated.

Neurologic:

• Mental status: alert and oriented to person, place, and time.
• Mood: No current signs of depression, anxiety, or suicidal ideations.
• Cranial Nerves:
  • CN II: visual fields intact 
  • CN III, IV, VI: PERRL, extraocular muscles intact with full range of movement
  • CN V: normal facial sensation, muscles of mastication are normal and symmetric.
  • CN VII: facial musculature is symmetric and expressions intact.
  • CN VIII: hearing is intact bilaterally to whisper test.
  • CN IX, X: normal palatal elevation, uvula is midline.
  • CN XI: sternocleidomastoid muscles are 5/5 bilaterally, trapezius muscles are 5/5 bilaterally.
• Sensation:
  • Light and dull touch: normal, symmetric in bilateral upper extremities
  • Pt admits to diminished sensation in his lower extremities bilaterally. 
  • No saddle anesthesia present
• Motor/cerebellar:
  • Not able to assess gait due to patient not being able to stand and or walk.
  • no pronator drift noted.
  • Not able to assess Romberg due to patient not being able to stand.
  • Get up and go test: not able to assess due to patient not being able to stand.
• Reflexes:
  • Bicep: Right 2+/4, Left 2+/4
  • Triceps: Right 2+/4, Left 2+/4
  • Brachioradialis: Right 2+/4, Left 2+/4.
  • Patellar: Right 2+/4, Left 2+/4
  • Achilles: Right 2+/4, Left 2+/4.
  • Plantar reflex: Babinski negative
• Mini-Cog: 5/5 (3/3 immediate recall, 3/3 delayed recall, 2/2 clock & time placement)

Musculoskeletal: No soft tissue swelling, erythema, ecchymosis, or deformities.

• Neck/Spine: No muscular atrophy noted. Kyphosis noted too upper thoracic. No evidence of scoliosis. No pain to palpation of spinous processes or paravertebral muscles. Neck flexion, extension, rotation, and lateral flexion intact without pain. 
• Shoulders: No atrophy noted. Flexion/extension 4/5 in strength and abduction/adduction 4/5 strength. External/internal rotation intact without pain B/L.
• Elbow: No atrophy noted. Flexion/extension 4/5 in strength B/L. No cog-wheel rigidity appreciated. 
• Hand/wrist: Symmetrical, no swelling, erythema or boney changes noted. Flexion and extension of wrist and fingers intact without pain. Grip strength 4/5 B/L.
• Hips: atrophy appreciated. Flexion/extension, external/internal rotation, and abduction/adduction intact without pain B/L. Pt had diminished strength 3/5 when flexing/extending at the hip B/L. The rest of the strength and other movement was 4/5 B/L.
• Knee: atrophy of quadricep muscle appreciated. Flexion/extension 3/5 in strength B/L. Pain with flexion/extension as well as external and internal rotation B/L. The rest of the strength and other movement was 4/5 B/L.
• Feet/ankles: No soft tissue swelling however atrophy noted B/L. Inversion/eversion & dorsiflexion/plantar flexion intact at 4/5 strength without pain B/L. 

Peripheral vascular: Extremities are symmetrical appear to be atrophied and hyperpigmented along the anterior aspect of the lower legs B/L. Normal in temperature. No edema or varicosities noted. Pulses 2+ bilaterally in upper and lower extremities. No calf tenderness.

Foot exam: Skin in warm and intact. No edema, erythema, lesions, or ulcers notes. 2+ dorsalis pedis and posterior tibial pulses bilaterally.

Labs:

CBC

Date                    WBC RBC HGB HCT MCV MCH MCHC

9/12/23                      12.44H 4.60  13.2  37.8  91.1  31.1  34.1

9/11/23                9.64  4.43  12.6  39.1  90.7  30.9  34.1

9/10/23                9.66  4.61  12.1  38.0  91.4  30.7  33.6

BMP

Date                    GLU BUN CREA        NA    K      CL    CO2  ANION

 9/12/23               175H 25H  1.1    131L 4.3    96L   27     8

9/11/23                129H 21     1.0    132L 4.3    98L   25     9

9/10/23                138H 22     1.0    129L 4.2    95L   25     9

Assessment/Plan:

85 y/o male patient originally planned for short stay rehab post fall and treatment of acute pneumonia and CHF exacerbation; however, he is adamant about being discharged home today with his husband who lives with him. 

Discussed benefits of remaining here for rehab with patient and his husband as well as the dangers of a discharge, however the patient insist on being discharged despite several attempts at persuading him to stay by his husband and medical provider. Patient has decisional capacity, and his husband is supportive of his decision. 

#Cough (pneumonia vs. CHF exacerbation) 

• s/p 5 days of Augmentin 
• s/p 2 days of azithromycin 
• azithromycin 250 mg PO daily x 4 days (due to increase in WBC per last CBC)
• continue Lasix 20mg PO daily. 
• encourage ambulation as tolerated. 
• PT/OT follow up outpatient. 
• Patient was advised to go to the emergency room if his symptoms worsen, do not improve, or if he develops a fever.

#HFrEF LVEF 40%

• Continue metoprolol succinate 50 mg PO daily. 
• Continue losartan 25 mg PO daily. 
• Salt restriction diet

 #Type II DM 

• Continue empagliflozin 10mg PO daily. 
• Monitor fingerstick daily, ideally 80-130 before meals and less than 180 after meals.
• Limit intake of concentrated sugar 

 #CAD 

• Continue atorvastatin 40 mg PO at night daily.
• Continue aspirin 81 mg PO daily. 
• Continue Clopidogrel 75 mg PO daily. 
• Continue Ranolazine 500 mg PO BID 

#HTN

• Continue amlodipine 5 mg PO daily. 
• Continue to monitor BP at home, ideally with SBP bellow 130.

#BPH

• Continue finasteride 5 mg PO daily. 
• Continue tamsulosin 0.4 mg PO daily. 

# Back pain

• Lidocaine 5% patch daily
• Capsaicin cream 0.025% liberal amount Q6H daily 
• d/c hydromorphone HCL 2mg Q6H PRN (Pt is not using it)
• Tramadol 50 mg PO Q6H PRN 
• Tylenol 1000mg PO Q8H 
• Encourage ambulation as tolerated. 
• PT/OT follow up outpatient. 

# Depression

• Continue citalopram hydrobromide 10 mg PO QHS
• Continue bupropion 12hr tab 150 mg PO Q12H
• Follow up with psychiatry outpatient.

# Glaucoma

• Continue latanoprost 0.005% 2.5 ML 1 drop OU QHS
• Continue dorzolamide HCL 2% solution OPH 1 drop OU daily. 
• Follow up with ophthalmologist outpatient. 

 # Supplementation

• Continue cyanocobalamin 1000 mcg PO daily.

# Disposition

• Pt is to be discharged home to care of husband w/home care referral and PCP f/u in 2-3 weeks.