Identifying Data:
Full Name: Mr. D
Address: Foresthill, NY
Date of Birth: June 24, 1933
Date & Time: January 15, 2020
Location: LTC-VA
Religion: Catholic
Source of Information: Self
Source of Referral: Self
Mode of Transport: Resident at LTC-VA
Chief Complaint: “I have a bad cough x 2 day”.
HPI:
Mr. D is an 87-year-old male with a PMHx of mild progressive dementia, multiple CVAs, hyperthyroidism, type 2 DM, paroxysmal atrial fibrillation and BPH was admitted to LTC-VA on April of 2016 because his family could no longer take care of him as he needed constant help with some of his IADL’s such as: preparing food for himself, handling his own medications and financial affairs. During his time as a resident at LTC-VA, Mr. D’s condition has been under control with no significant medical complications.
The morning of January 15th, 2020, Mr. D was seen due to complains of bad cough. Mr. D states he was doing nothing in particular when he started experiencing severe cough as he was laying down in bed. Cough started 2 days ago, occurring mostly at night and he states that the cough lasts between 20 to 30 mins and the only thing that seems to make it better is sitting up and drinking water. Mr. D describes the cough as non-productive and dry. The cough keeps Mr. D up at night and is associated with mild fever (this is subjective, he did not measure it) and vomiting. He describes vomiting as yellowish mucus mixed with previous food that he had eaten prior to it and so far, has vomited 2 times, once last night and once early this morning. Both times, the amount of vomiting has been a handful. Mr. D states the cough irritates the back of his throat and that irritation pain is a 5/10 on the severity scale. Mr. D denies SOB, wheezing, hemoptysis, dysphagia, swelling of the neck, cyanosis, orthopnea, nausea, sore tongue, lumps, nasal congestion, lacrimation, headaches, rhinorrhea, palpitations, diarrhea, syncope, known heart murmur, claudication, leg edema and dyspnea on exertion.
It’s important to also note that Mr.D’s roommate was diagnosed with Influenza A last week and the roommate is currently taking Tamiflu.
Past Medical History:
Present illnesses – Type 2 DM x 6 years; mild progressive dementia x 4 years; hyperthyroidism x 2 years; paroxysmal atrial fibrillation x 3 years; BPH x 7 years.
Past medical illnesses – Multiple CVA’s (2 separate cases; 2013 and 2015). Loss of consciousness when he had the first episode of CVA back in 2013 and states that his memory hasn’t been the same since then and states he’s very forgetful now. In 2015, the symptoms were recognized early, avoided complications.
Hospitalized each time for each CVA: sent home on ASA and educated on recognizing early symptoms of possible CVA in the future.
Childhood illnesses –Denies childhood illnesses.
Immunizations – Up to date, except yearly influenze shot. He refused it.
Screening tests and results– Screening colonoscopy 2015, benign.
Past Surgical History:
Denies past surgical history, past injuries or transfusions.
Medications:
Eliquis, 2.5 mg PO, 1-tab q12h, to prevent clot formation due to Afib, last dose was last night.
Baby Aspirin 81mg, 1 tab PO daily, cardioprotective & CVA prevention, last dose last night.
Diltiazem 240 mg, PO q12h, rate control for Afib, last dose last night.
Divalproex (Valproic acid), 1000 mg PO, for mood stabilizer, every night before bedtime.
Finasteride 5 mg PO daily for BPH, last dose was yesterday at lunch time.
Flomax 0.4 mg PO at bedtime for BPH, last dose was last night.
Trazodone HCL, 25 mg, PO before bedtime for anxiety, last dose was last night.
Methimazole 30 mg PO 3 times a day for hyperthyroidism, last done was last night.
Galantamine 4 mg PO twice a day after meals for dementia, last dose was last night.
Multivitamins CAP/TAB 2 tablets PO daily supplement for overall health.
Allergies:
Denies drug, environmental or food allergies.
Family History:
Mother – Deceased at age 84, stroke.
Father – unknown.
Wife- Deceased at age 69, ovarian cancer.
Daughter – 53, alive and well
Maternal/paternal grandparents – Deceased at unknown age & unknown reasons
Denies family history of cancer.
Social History:
Mr. D is a Korean war veteran, army- combat engineer, Stationed in Fort
Orlando Airforce Base 1958-1959 and served in the US Army for about 10 years before retiring. Before becoming a resident at the LTC-VA he was living with his daughter, her husband and 2 of their kids, but as he got older, he could no longer take care after himself so they decided to admit him at the VA.
Habits- Mr. D used to smoke tobacco for 20 years (on and off), about 1 pack a day (20 pack-year). He quit 3 years ago. He denies alcohol use in the present and past and also no illicit drug use, past or present.
Travel- Has not recently traveled anywhere.
Diet- Not on a particular diet. He usually eats whatever the nurses bring him. Occasionally he will ask for a chocolate cake. He says that’s his favorite.
Exercise- He goes for OT/PT once a week at the VA.
Sexual Hx- Not sexually active. No past history of any STDs or HIV.
Review of Systems:
-General – Resident states he has loss appetite, also reports mild fever (subjective, did not actually measure it). Denies recent weight loss or gain, generalized weakness/fatigue, or night sweats.
Skin, hair, nails – Denies changes in texture, excessive dryness or sweating, discolorations, pigmentations, moles/rashes, pruritus or changes in hair distribution.
Head – Denies headaches, vertigo or head trauma.
Eyes – Denies lacrimation, pruritis, visual disturbances, or photophobia. Last eye exam 2016 – does not know his visual acuity; normal pressure.
Ears – Denies deafness, pain, discharge, tinnitus or use of hearing aids.
Nose/sinuses – Denies discharge, obstruction or epistaxis.
-Mouth/throat – Resident states that the cough irritates the back of his throat and has non-productive dry cough. Denies bleeding gums, sore tongue, mouth ulcers, voice changes. Last dental exam 2018, normal.
Neck – Denies localized swelling/lumps or stiffness/decreased range of motion
Breast – Denies lumps, nipple discharge, or pain.
-Pulmonary system – Resident states he has severe cough that irritates his throat that leads to pain as well. Denies dyspnea, dyspnea on exertion, wheezing, hemoptysis, cyanosis, orthopnea, or paroxysmal nocturnal dyspnea (PND).
-Cardiovascular system – Resident states he has Afib and sometimes he feels slight chest palpitations and irregular heartbeats when he touches his pulse. Denies chest pain, edema/swelling of ankles or feet, syncope or known heart murmur.
-Gastrointestinal system – Resident states he has vomiting associated with cough. He has vomited twice and he describes it as yellowish mucus mixed with previous food that he had eaten prior to it. Has regular bowel movements daily. Denies intolerance to specific foods, nausea, dysphagia, pyrosis, unusual flatulence or eructations, abdominal pain, diarrhea, jaundice, hemorrhoids, constipation, rectal bleeding, or blood in stool.
-Genitourinary system – Resident states he has nocturia, wakes up at least once at night to urinate. Denies urinary frequency or urgency, oliguria, polyuria, dysuria, incontinence.
-Nervous – Resident states he had loss of consciousness when he had the first episode of CVA back in 2013. He also states he doesn’t remember as well as he used to in the past. Denies seizures, headache, sensory disturbances, ataxia, loss of strength, change in cognition / mental status/
Musculoskeletal system – Denies muscle/joint pain, deformity or swelling, redness or arthritis.
Peripheral vascular system – Denies intermittent claudication, coldness or trophic changes, varicose veins, peripheral edema or color changes.
Hematological system – Denies anemia, easy bruising or bleeding, lymph node enlargement, blood transfusions, or history of DVT/PE.
Endocrine system – Denies polyuria, polydipsia, polyphagia, heat or cold intolerance, excessive sweating, hirsutism, or goiter
Psychiatric – States he sometimes feels anxious at nights when he can’t fall asleep. Denies mood changes, depression. Denies sadness, OCD.
Physical exam:
General: Resident is alert and oriented x3, neatly groomed, no apparent distress and responsive to verbal commands.
Vital Signs: BP: R L
Seated 117/78 123/89
Supine 109/72 123/77
R: 20/min unlabored P: 98, regular
T: 99.8 degrees F (oral) O2 Sat: 96% Room air
Height 73 inches Weight 179.3 lbs. BMI: 23.6
Skin: warm to the touch & moist, good turgor. Nonicteric, no lesions noted, no scars, tattoos.
Hair: Pt is bald.
Nails: no clubbing, capillary refill <2 seconds throughout.
Head: normocephalic, atraumatic, non-tender to palpation throughout
Eyes – symmetrical OU; no evidence of strabismus, exophthalmos or ptosis; sclera white;
conjunctiva & cornea clear.
Visual acuity (uncorrected – 20/40 OS, 20/40 OD, 20/40 OU).
Visual fields full OU. PERRL, no accommodation, EOMs full with no nystagmus
Fundoscopy – Red reflex intact OU. Cup: Disk < 0.5 OU/no evidence of A-V nicking, papilledema, hemorrhage, exudate, cotton wool spots, or neovascularization OU.
Ears: Symmetrical and normal size. No evidence of lesions/masses / trauma on external ears. No discharge / foreign bodies in external auditory canals AU. TM’s pearly white / intact with light reflex in normal position AU. Auditory acuity hardly intact to whispered voice AU. Weber midline / Rinne, BC<AC AU.
Nose – Symmetrical / no obvious masses / lesions / deformities / trauma / discharge. Left nostril congestion due to mucus. Nasal mucosa pink & appears dehydrated. No discharge noted on anterior rhinoscopy. Septum midline without lesions / deformities / injection / perforation. No evidence of foreign bodies.
Sinuses – Non tender to palpation and percussion over bilateral frontal, ethmoid and maxillary sinuses.
Lips – Pink, crusty; no evidence of cyanosis or lesions. Non-tender to palpation.
Mucosa – Pink ; dehydrated. No masses; lesions noted. Non-tender to palpation.
No evidence of leukoplakia.
Palate – Pink; dehydrated. Palate intact with no lesions; masses; scars. Non-tender to palpation; continuity intact.
Teeth – Missing a few front teeth / 2 dental caries noted.
Gingivae – Pink; dehydrated. No evidence of hyperplasia; masses; lesions; erythema or discharge. Non-tender to palpation.
Tongue – Pink; well papillated; no masses, lesions or deviation noted. Non-tender to palpation.
Oropharynx – dehydrated and redness noted in the back of oropharynx; no evidence of injection; exudate; masses; lesions; foreign bodies. Tonsils present with no evidence of injection or exudate. Uvula pinkish, no edema, lesions.
Neck – Trachea midline. No masses; lesions; scars; pulsations noted. Supple; non-tender to palpation. no stridor noted. 2+ Carotid pulses, no thrills; bruits noted bilaterally.
Thyroid – Thyromegaly noted on palpation. Non-tender; no palpable masses; no bruits noted.
Thorax & Lungs:
Chest– symmetrical, no deformities, no evidence of trauma. Respirations unlabored, no paradoxical respirations or use of accessory muscles noted. Lat to AP 2:1, non-tender to palpations.
Lungs– Clear to auscultation and percussion bilaterally. Chest expansions and diaphragmatic excursions symmetrical. Tactile fremitus symmetric throughout. No adventitious sounds.
-Heart: Irregular rate and rhythm during the time of examination. No tenderness to palpation. JVP is 2.5 cm above the sternal angle with the head of the bed at 30°. PMI in 5th ICS in mid-clavicular line. Carotid pulses are 2+ bilaterally without bruits; There are no murmurs, S3, S4, splitting of heart sounds, friction rubs or other extra sounds.
Abdomen: No hernias noted. Flat / symmetrical / no evidence of scars, striae, caput medusae or abnormal pulsations. BS present in all 4 quadrants. No bruits noted over aortic/renal/iliac/femoral arteries. Tympany to percussion throughout. Non-tender to percussion or to light/deep palpation. No evidence of organomegaly. No masses noted. No evidence of guarding or rebound tenderness. No CVAT noted bilaterally.
Male genitalia:
Circumcised male. No penile discharge or lesions. No scrotal swelling or discoloration. Testes Descended bilaterally, smooth and without masses. Epididymis nontender. No inguinal or femoral hernias noted.
Anus, Rectum, and Prostate
No perirectal lesions or fissures. External sphincter tone intact. Rectal vault without masses. Prostate enlarge on DRE and nontender with no palpable median sulcus. Stool brown and Hemoccult negative.
Peripheral Vascular:
The extremities are normal in color, size and temperature. Pulses are 2+ bilaterally in upper and lower extremities. No bruits noted. No clubbing, cyanosis or edema noted bilaterally (no C/C/E B/L) No stasis changes or ulcerations noted.
|
|
Brachial
|
Ulnar
|
Radial
|
Femoral
|
Popliteal
|
D.P.
|
P.T.
|
| R
|
2+
|
2+
|
2 +
|
2+
|
2+ | 2 +
|
2 +
|
| L
|
2+
|
2+
|
12+
|
2+
|
2+ | 2+
|
2+
|
Upper & Lower Extremities:
No soft tissue swelling / erythema / ecchymosis / atrophy / or deformities in bilateral upper and lower extremities. Non-tender to palpation / no crepitus noted throughout. FROM of all upper and lower extremities bilaterally. No evidence of spinal deformities.
Cranial nerves:
I . Olfactory: intact bilaterally
- Optic: OD OS
visual acuity 20/40 20/40 (uncorrected)
visual fields ( restricted )
fundoscopic examination: (see eye exam)
III. Oculomotor, IV Trochlear, VI Abducens:
extraocular movements (intact), no nystagmus, ptosis.
direct and consensual pupillary light reflex intact bilaterally
accommodation restricted bilaterally
- Trigeminal: masseter/temporalis strength 5/5
corneal reflex intact OU.
VII. Facial: facial movements intact.
VIII. Acoustic: auditory acuity intact bilaterally to whispered voice, Weber: midline, Rinne: AC>BC
- Glossopharyngeal,
X Vagus: uvula midline, soft palate and pharynx rise symmetrically
- Spinal Accessory: sternocleidomastoid strength 4/5 bilaterally,
trapezius strength 4/5 bilaterally
XII. Hypoglossal: no tongue atrophy, deviation upon protrusion or fasciculations noted
Motor Systems no evidence of atrophy, fasciculations or abnormal movements
normal muscle bulk, contour and tone
Muscle Strength: Right Left
upper extremities 5/5 5/5
lower extremities 5/5 5/5
rapid alternating movements and point to point movements intact, no asterixis
gait normal, Romberg negative, slight pronator drift
Sensory Systems dull, thermal and light touch sensation intact upper and lower extremities bilaterally, vibratory sensation intact over great toe bilaterally
proprioception, stereognosis, graphesthesia, two-point discrimination, point localization and extinction intact
Reflexes
Biceps Brach. Triceps Abd Knee Ankle Plantar Response
RT 2+ 2+ 2+ 2+ 2+ 2+ Down-going
LT 2+ 2+ 2+ 2+ 2+ 2+ Down-going
Meningeal Signs
No nuchal rigidity noted. Brudzinski’s and Kernig’s signs negative.
Cognitive assessment
Mini- mental exam:
What year is it: 4/5 (couldn’t say if it was Monday or Tuesday)
Where are we: 4/5 (didn’t know the name of the hospital)
Give names of 3 objects. Ask resident to repeat all 3 then ask them to remember. 3/3
Serial 7’s from 100 to 5 answers or spell the word “world” backwards: 2/5
Ask for the 3 objects named above: 1/3 (was only able to remember one)
Test giver points to pencil and watch and the resident names them: 2/2
Repeat the following: “No ifs, ands or buts” 1/1
Follow 3 commands: take paper, fold it in half, put it on the floor” 1/1
Read and obey the following: CLOSE YOUR EYES: 1/1
Write a sentence: 1/1
Copy a design: 0/1
Total score: 20/30
Assessment and Plan:
Mr. D is an 87-year-old male with a PMHx of mild progressive dementia, multiple CVAs, hyperthyroidism, type 2 DM, paroxysmal atrial fibrillation and BPH was admitted to LTC-VA on April of 2016 because his family could no longer take care of him as he needed constant help with some of his IADL’s.
- Cough
– Administer Dextromethorphan HBr sugar-free 10ml prn for cough.
– Administer Acetaminophen, 325 mg PO, prn, only if he develops fever or can also use for throat pain due to cough.
- BPH -stable
-last US 2017 : Enlarged prostate gland with some amount of
postvoid residual in the bladder.
– Pt tolerating well Finasteride and Flomax.
- Paroxysmal Afib -stable
– Continue rate controlled on Diltiazem
– Continue on Eliquis for prevention of clot formation.
- Mild progressive dementia- stable
– Continue on Divalproex, 1000 mg PO and Galantamine 4 mg PO twice a day and Trazodone HCL, 25 mg for anxiety.
- History of multiple CVA- stable
– Continue on baby Aspirin, 81mg, 1 tab PO daily.
- Hyperthyroidism/ enlarged thyroid gland – stable
– 07/12/2019: TSH: 0.520 T4: 5.4 (WNL)
Thyroid US on 10/24/19: no changes.
– Continue on Methimazole 30 mg PO 3 times a day.
- Type 2 Diabetes Mellitus/h/o hypoglycemia -stable
– Hgb A1C 6.5 on 6/5/19
- Prevention
– DVT ppx: ambulates well on his own regularly with a walker and baby aspirin
– Multivitamins CAP/TAB 2 tablets PO daily supplement for overall health.
- PROGNOSIS: Fair
DECISION MAKING CAPACITY: Slightly Limited
DNR: Full code
ADVANCE DIRECTIVES: Yes (daughter)
DISCHARGE PLAN: continue further LTC here at St Albans CLC.
DDX:
- Influenza A (most likely because resident presents with no fever and some symptoms similar to Influenza A. His roommate was diagnosed with influenza A last week so he might’ve passed it to him.
- Common cold (could also be common cold caused by rhinovirus since its also peak season for the flu)
- Bacterial URI (less likely due to no symptoms of fever, no productive cough. Most signs point toward a viral URI).
Plan:
-Perform a rapid molecular assay, by swabbing the resident’s nose and throat. Confirm for influenza A.
If confirmed influenza A then:
-Administer Tamiflu 75mg PO twice a day for 5 days.
-Administer Acetaminophen, 325 mg PO, prn, only if he develops fever or can also use for throat pain due to cough.
-Administer Dextromethorphan HBr sugar-free prn for cough.
-Continue all medications mentioned in the assessment section.
-Isolate the resident from the rest of the residents in the floor until symptoms subside and encourage frequent hand washing.
-Continue to monitor the resident’s vitals and baseline status.
This entry is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International license.
