LTC HPI 3

 History of Present Illness:

87 y/o male fully dependent in ADLs in wheelchair presents to the geriatric clinic with PMHx of hyperlipidemia, arterial hypotension, complete heart block,sick sinus syndrome, sinus node dysfunction  pre-diabetes ,GERD, history of prostate cancer  BPH, vascular parkinsonism with daughter to follow up on digoxin level. Last visit Digoxin 125 mcg once every other day was added to his regimen due to progressing hypotension and orthostatism. Patient was last seen in the clinic 04/03/2024 with a blood pressure of 88/51. Patient was asymptomatic and denied any dizziness or lightheadedness(limited response due to patient neurological condition). Patient was also prescribed salt tablets to help increase blood pressure. Patient blood work was done a week prior to see whether the patient was in therapeutic range.

Patient’s daughter also states that her father is having lower neck pain/ sore throat(unclear). Daughter states her father has localized pain in the lower neck region when head is turned throughout the day. Daughter is also stating that dad has discomfort in his throat and hears her dad have to frequently clear his throat throughout the day. Further information was unable to be obtained from patient due to neurological condition   

Geriatric Assessment

  • ADLs: Needs assistance in transferring, toileting and grooming. Full dependence 
  • IADLs: Needs assistance in meal preparation, household chores, transportation, paying bills, shopping and taking medications. Full dependence   
  • Home Health Aide: None
  • Visual impairment: Yes – wears glasses
  • Hearing impairment: Yes- Left side hearing impairment 
  • Falls in the past year: 2 in the past year 
  • Assistive devices used: Yes- Wheelchair outside home 
  • Gait impairment: Yes- heavy assist- WC dependent 
  • Urinary incontinence: Yes- Urgency 
  • Fecal incontinence: None
  • Osteoporosis: Unknown 
  • Cognitive Impairment: Yes – ⅓ , unable to draw a clock. Mini-COG  1/5
  • Depression: None 
  • Home safety issues: None
  • Health Care Proxy: Daughter 
  • Advance Directives: Full code

Past Medical History

Medical History:

  • Hyperlipidemia
  • Arterial Hypotension
  • Complete heart block(Pacemaker)
  • Sick Sinus syndrome 
  • Sinus node dysfunction
  • Pre-Diabetes  
  • GERD
  • History of Prostate cancer  
  • BPH
  • Vascular Parkinsonism 

Medications:

  • Atorvastatin (LIPITOR) 10 mg one tablet daily
  • Digoxin(LANOXIN)  125 mcg tablet PO once every other day
  • Pantoprazole(PROTONIX) 40 once mg tablet 
  • Tamsulosin(Flomax) 0.4 mg one capsule daily
  • Sodium Chloride 1g tablet PO BID
  •  Carbidopa- Levodopa(SINEMET) 25-250 mg tablet three times daily.

Surgical History:

  • Phrenic nerve pacemaker implantation(Date unknown)

Immunization History:

  • Pfizer COVID-19 12+(2023-2024 formula): 11/29/2023
  • Influenza: 11/29/2023
  • TDAP: 07/28/2023
  • PNEUMOCOCCAL  20: 01/27/2023
  • SHINGRIX: 04/03/2024, 07/28/2023

Allergies: 

  • No known drug/food/environmental allergies

Family History:

  • Mother: Deceased at unknown age.Hx of HTN
  • Father: Deceased at 75. Hx of heart disease
  • 1 Child: Alive and well, lives with father,

Social History:

  • Smoking: Former smoker- 30 years (0.25 packs/day)
  • Alcohol: Never
  • Denies past or current illicit drug use
  • Marital History: Widower(2018)
  • Language: English
  • Education: High school education 
  • Occupational History: Retired, Janitor for 40 years.
  • Travel: No recent travel
  • Home situation: Patient with his daughter in an apartment building, is taken care of fully by her.  
  • Sleep: Daughter states patient sleeps well.
  • Exercise: Patient unable to exercise(Wheelchair bound)
  • Diet: Patient eats a soft food diet 
  • Caffeine: Denies caffeine intake 
  • Sexual history: Not currently sexually active. No known history of STIs.

ROS:

–ROS responses limited due to dementia 

Physical Exam:

Vitals: 

  • Weight: 124  lb Height: 65   BMI:20.6
  • BP: 88/51, left arm sitting
  • RR: 18, unlabored
  • HR: 70, regular
  • Temp: 97.1 F oral
  • SpO2: 98% room air

General: 87 year-old slim ill appearing male, not in any 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.

Ears: Cerume in ears . Ears symmetric and appropriate in size. No lesions or masses on the external ear. TM clearly visualized, pearly gray & in good position AU. Auditory acuity intact to whispered voice AU.

Nose: Symmetrical. No rhinorrhea noted. Nares patent B/L.

Mouth/Throat: Mucus membranes dry. Pharynx non-erythematous. No exudates present.

Neck: Trachea midline. Neck supple and nontender. No lymphadenopathy present. Carotid pulses 2+. Right sided carotid artery bruit auscultated. FROM without pain.

Thyroid: Non-tender to palpation, no thyromegaly noted, no palpable nodules or masses.

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

Chest: Symmetrical, no deformities. Non-tender to palpation. Chest expansion symmetrical with no accessory muscle use.

Lungs: Clear to auscultation B/L. No adventitious sounds noted.

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. Negative Murphy’s sign.

Neurologic. Motor- weakness present. Coordination abnormal and abnormal gait(ADVANCED DEMENTIA). Right Hemiparesis- Right parkinsonism  

Musculoskeletal: Decreased ROM in all extremities due to rigidity.No soft tissue swelling, erythema, ecchymosis or deformities.

Peripheral vascular: Extremities are symmetrical and normal in size, color and temperature. No edema or stasis changes noted. Pulses 2+ bilaterally in upper and lower extremities. No calf tenderness.

Foot exam: Skin is warm and intact. No edema, erythema, lesions or ulcers notes. Nails well-trimmed and appropriate in length. 2+ dorsalis pedis and posterior tibial pulses bilaterally.

Assessment/Plan:

87 y/o male with pmhx of hyperlipidemia, arterial hypotension, complete heart block,sick sinus syndrome, sinus node dysfunction  pre-diabetes ,GERD, history of prostate cancer  BPH, vascular parkinsonism comes in today to follow up on digoxin level. Patients’ Digoxin level is at goal(0.8) and is currently improving on treatment. Patient’s unclear symptoms makes it hard to make a diagnosis on sore throat/neck pain and will be given topical pharyngeal spray and pain relief.

#Arterial Hypotension 

  • Improving on digoxin – BP better with acceptable MAP- Dig level is at goal- electrolytes controlled.
  • Educated on adding black tea or black coffee in the morning to help increase blood pressure.

#Secondary Parkinsonism

  • Continue Carbidopa- Levodopa(SINEMET) 25-250 mg tablet three times daily.

#Sore Throat

  • Use Phenol 1.4 %(Chloraseptic) Liquid spray

#Neck Pain

  • Use Menthol, Topical Analgesic, 16 % cream 1 application twice daily on affected joint

#History of prostate cancer

  • In remission

#Complete heart block(PACEMAKER)

  • Follows with Cardiology 

#BPH 

  • Tamsulosin removed last visit, on salt tabs 

#Hyperlipidemia

  • Lipid abnormalities are improving with treatment(Atorvastatin 10 MG tablet once daily)
  • Will be reassessed in 1 year. 

#GERD

  • Continue to take Pantoprazole 40 mg tablet- symptoms well controlled. 

#Pre-diabetes

  • Diet and weight control 

#Healthcare Maintenance

  • RSV vaccine today