Chief Complaint: “new admission evaluation”

HPI

82 y.o. legally blind male who lives in a private home with his sister, niece and great-niece with PMHx of HTN, glaucoma, atrial fibrillation, dementia, and PUD presents with his niece accompanying him as a new admission to the St. Albans Adult Day Health Care program. At the time of admission, the patient admits difficulty seeing secondary to glaucoma OS>OD and diminished hearing in bilateral ears for many years. Additionally, the patient endorses recent (approximately 1 month) history of visual hallucinations. He states that he usually sees people who aren’t there or boxes either around himself or other objects in the room. He states that the visions are non-threatening, there is no auditory component, and that this has not happened to him before in the past. The patient endorses history of nocturia, sometimes as often as 7-8x/night. He denies all other complaints at this time including recent fever, chills, cough, CP, SOB, DOE, N/V, change in bowel habits, dark stool, dysuria, urinary frequency, hematuria, change in appetite, or unintended weight loss.

The patient is able to ambulate with the aid of a rollator, but needs assistance when walking secondary to poor vision. Additionally, he requires assistance with toileting. The patient is able to eat food like sandwiches unaided but needs help with meals that require the use of a fork or spoon. Patient requires assistance from family for self-grooming and has minimal capabilities with IADLs secondary to poor vision. He states that his niece takes him outside for walks on most days and to run errands like going to the grocery store. When home he usually watches TV or listens to the radio.

Of note, the patient was recently relocated from Maryland where he was living in a senior center in his own private apartment after he thought he heard someone knocking at his front door at 4:30am, subsequently locked himself out of his apartment and was unable to gain re-entry. The police were called and the patient became upset and confused so was transported to an area hospital. His discharge from the hospital was predicated on having a family member reside with him. This could not be achieved so the patient’s niece drove down to Maryland to pick him up and bring him to live with herself, her mother and her daughter. Prior to the incident described above, the patient’s family had noticed a decline in cognitive function. The patient’s niece states that he was seen by a doctor in Maryland where he also had imaging of the brain done and was given a diagnosis of dementia, but that they have yet to be able to retrieve the patient’s hospital records.

PMH

Legally blind

Glaucoma

Atrial fibrillation

Dementia

PUD

PSH

Ex-lap for ulcer resection (1990s)

Left second finger surgery s/p injury in garage door (2001)

Eye surgery (multiple, unclear on dates)

MEDS

Atenolol 50mg PO qd

Dorzolamide 22.3/Timolol 6.8mg/mL, ophthalmic 1 drop in each eye BID

Latanoprost 0.005% solution, ophthalmic 1 drop in each eye qd

Netarsudil 0.02% solution, ophthalmic 1 drop in each eye qd

Apixaban 5mg PO BID

ALLERGIES

NKDA

FHx

Father: deceased at 49 years – accident/fall

Mother: deceased in her 80s – unknown cause

Brother: deceased at 77 – heart disease

Sister: 84 alive and well – thyroid problem

Sister: 79 alive and well – dementia

SHx

The patient is unmarried and lives in a private home with his sister, niece and great-niece. He recently relocated to New York from Maryland after it was determined that he needed more care than he was getting at his previous residence. He achieved a middle school-aged education and worked as a sanitation worker and in maintenance before retiring in the early 2000s. He has no children, but a large family that he is reasonably well-connected with. He admits a 15-pack year smoking history but quit 20+ years ago. He denies illicit drug use and states that he drinks alcohol on social occasions.

ROS

Constitutional: negative for fever, chills, weakness and fatigue. Appetite is unchanged.

HEENT:

– Eyes: progressively worsening vision, no photophobia, glasses worn

– Ears: decreased hearing in both ears

– Nose: no epistaxis or obstruction

– Mouth and throat: no ulceration, hx of candidiasis, or denture use

Neck: no lumps, localized swelling or stiffness

Respiratory: No SOB, cough, wheezing, hemoptysis, PE, pneumonia, TB or TB exposure

Cardiac: no recent CP, palpitations, syncope, known murmur

GI: denies abdominal pain, nausea, vomiting, constipation, diarrhea, BRBPR, or dark tarry stools

GU: Admits nocturia, denies urinary frequency, urgency, dysuria, or hematuria

Musculoskeletal: denies arthralgias and myalgias

Extremities: denies swelling or intermittent claudication

Skin: denies rash or ulceration

Neurological: negative for headaches or visual changes

Psychiatric: denies symptoms of depression, sense of hopelessness, loss of interest in usual activities, suicidal or homicidal ideations

PE

VS: BP 134/86 left arm, seated; pulse 71 irregular; O₂ sat 99% room air; respirations 16/min; temp 98.8°F oral; height 75.5 inches; weight 154.5lbs, BMI 19.8

Patient is alert and oriented x 3, pleasant, appropriately dressed, NAD

HEENT:

– Head: normocephalic atraumatic, face symmetric

– Eyes: 20/70 OS, 20/50 OD, 20/50 OU, PERRL (left eye sluggish), EOMI, poor peripheral vision to confrontation bilaterally, left lens cloudy in appearance, conjunctiva clear, no scleral icterus

– Ears: symmetric, TMs intact and pearly grey, decreased hearing to whispered voice bilaterally

– Nose: patent, septum midline, clear rhinorrhea, turbinates pink

– Mouth and throat: uvula rise midline, oropharynx clear and moist, dentition intact, no lesions

Neck: FROM, trachea midline, no palpable cervical adenopathy, no thyromegaly, carotids 2+ bilaterally

Heart: irregularly irregular rhythm, S1/S2, no heaves, gallops, murmurs

Lungs: CTA bilaterally, no wheezing, crackles, or ronchi, no retractions or accessory muscle use

Abdomen: soft, nontender, nondistended with 5cm midline scar, bowel sound active, no rebound/guarding or masses, no CVA tenderness

Extremities: warm, no edema

Musculoskeletal:

– UE: FROM of bilateral wrists, elbows and shoulders

– LE: FROM of bilateral toes, ankles, knees with crepitus noted on passive ROM of bilateral knees, mildly decreased ROM of bilateral internal and external rotation of the hips

– Spine: no tenderness to palpation, decreased ROM with flexion, extension, and lateral bend

Skin: intact, no lesions or ulceration noted, good turgor, no jaundice, capillary refill < 2 seconds throughout

Neuro: A&O x 3, MOCA 16/30. Sensory is intact for temperature, light touch, pin and diminished for vibratory sense of bilateral feet. Motor: grasp 5/5, remaining motor of BUE 5/5, hip 4/5, knee 4/5, ankle 5/5. Cerebellar: unable to perform finger-to-nose secondary to vision problem heel-to-shin slow, gait is narrow with short stride, unsteady and slow, but improves with the use of rollator.

LABS

CBC: WBC 5.6; Hgb/Hct 13.5/41.2; Platlets 219k; MCV 92.4

CMP: Glucose 99, electrolytes all wnl; BUN/Cr 22/1.2

Hgb A1C: 5.9

Lipid panel: CHOL 187; TRIG 81; HDL 41; LDL 129.8

HEMOGLOBIN A1C (NEW)       10/30/19 09:59    5.9

Hepatitis A NEGATIVE

Hepatitis B NEGATIVE

Hepatitis C NEGATIVE

TSH 1.366

VitD 21.3

Folate 20.20 (HIGH)

DDX:

• Vascular dementia
• Lewy body dementia
• Alzheimer’s dementia

ASSESSMENT/PLAN

1. HTN, stable BP today 134/86-

– Continue Atenolol 50mg PO qd

2. Glaucoma, progressive but adequately managed

– Continue Dorzolamide 22.3/Timolol 6.8mg/mL, ophthalmic 1 drop in each eye BID

– Continue Latanoprost 0.005% solution, ophthalmic 1 drop in each eye qd

– Continue Netarsudil 0.02% solution, ophthalmic 1 drop in each eye qd

3. Positive dementia screen (MOCA 16/30)

– Neuropsychiatric evaluation

– B12 ordered

– RPR ordered

– MRI head ordered

4. Atrial fibrillation, stable HR 71 irregular

– Continue Apixaban 5mg PO BID

5. Nocturia, patient is drinking 6 large glasses of water per day

– Restrict fluids in the evening

6. Low BMI, stable pt is reported to be thin throughout his life

– Patient educated on home exercise program and advised to do once daily with supervision to maintain UE and LE strength and balance

7. PUD, stable

– Follow with GI prn