History & Physical

History

Identifying Data:

Name: JS

Address: Queens, NY

Date of Birth: 12/26/1949

Date & Time: September 23 2022, 11:00 AM

Location: VA St Albans, St Albans, NY

Sex: Male

Marital Status: Single

Religion: Catholic 

Nationality: African American 

Source of Information: Self and previous medical notes

Reliability: Reliable

Source of Referral: Self

Chief Complaint:

“My left lower leg is weak”

HPI

Mr JS is a 72 y/o widowed male patient who used to live at home with his son, but currently resides at St. Albans VA. He is unable to ambulate and has a motorized wheelchair He is dependent on his ADLs and IADLs but is able to eat on his own.  His PMHx includes dementia, HTN, HLD, aortic aneurysm (dx 01/2022), gastric reflex, pulmonary embolism,  CAD and depression, CVA w/hemiparesis.

On 01/25/2022, he was sent to the  ER after he was found on the floor of his apartment. He was admitted to Manhattan VA for a change in mental status. Work-up was significant for multiple pulmonary emboli on chest CT. Venous doppler was negative for DVT although started on therapeutic anticoagulation. Neuro and psych both following for change in mental status. Head CT and brain MRI showed chronic microvascular disease. Lab workup negative for reversible causes of dementia. Also noted cogwheeling and bradykinesia on exam. Donepezil 5 mg daily was initiated on 1/29/22. There was also an episode of agitation on 1/30 for which he received zyprexa.  On 2/7/22 he was re-examined by by neuro for continued L leg weakness, found proximal weakness at left hip extensor and knee extensor, recommended CT to r/o retroperitoneal hematoma as rare cause of L sided weakness, also MRI C spine and L spine which found diffuse degenerative disease.  However on repeat exam he had full strength in L leg, therefore leg weakness thought to be related to delirium

vs. dementia. His mental status slowly improved, became AOx3 though with some mild short term memory loss. He no longer said that L leg was paralyzed and began to initiate leg exercises by himself. He received in-patient OT & PT program but no improvement with self care skill, transfer or ambulation safely. Since there is no known next of kin, and his mental status wax-wane, he was transferred to St. Albans B3 for long term care.

Patient was accepted and transferred to VA St Albans on 02/14/22.  On admission, the resident repeatedly stated that his HTN medication caused him to faint and fall and he does not want to take it anymore.  He states that he is now slowly regaining his memory. His reported stay at the hospital made him feel better and now hopes to regain his baseline functional status so he can go home. He is currently ℅ of his left lower extremity being weak which is preventing him from walking. There is no radiation of the weakness, rates it 8/10, starts from his left hip to his left ankle. He denies pain, numbness, tingling. Reports nothing aggravates or alleviates the weakness. He just feels that it’s weak the same way throughout the entire day and that the left lower extremity lacks strength. He states he is afraid to walk because he does not think he can place weight on his left lower extremity.  Denies any dyspnea, wheezing, hemoptysis, cyanosis. Pt denies any chest pain, edema in legs, or any syncope. Pt denies any sensory disturbances including numbness, paresthesias, dysesthesias. Pt denies any chest pain, edema in legs, or any syncope.

Geriatric Assessment:

ADLs: Currently (after injury), dependent in all besides eating.

IADLs: Dependent after fall

Visual impairment: 20/20 vision with glasses

Hearing impairment: No hearing impairment documented, or evident during  whisper test or during conversation with patient.

Falls in the past year: One fall on record on  01/25/2022.

Get up and go: Unable to perform due to inability to ambulate

Assistive devices used: Prior to injury, no assistive devices needed.  Currently patient is in a wheelchair

Gait impairment: Currently unable to ambulate

Urinary incontinence: infrequent incontinence. Patient states that “once in a while” he urinates a “small amount” without realizing.

Fecal incontinence: none

Osteoporosis: No diagnosis of osteoporosis.

Depression: patient has been “depressed” and “sad” at times since his wife passed away 10 years ago.

Home safety: Patient lives at home alone with his son. Patient reports that prior to his questionable fall/episode

he was steady on his feet and did not need assistance with walking. He reports his home is well lit and carpeted throughout.

Health Care Proxy: Son

Advanced directives: Patient has advanced directives

Elder abuse: no signs of bruising or other injuries

 Past Medical History

HLD X 25 years

HTN X 30 years

Depression X 10 years

Aortic Aneurysm (01/2022)  ascending thoracic aorta,5.1 cm

Past Surgical History

No PSHx

Medications:

Apixaban Oral 5 MG Q12 hours

Atorvastain 80mg PO

Cholecalciferol 25 MCG PO

Donepezil HCL 5MG PO

Melatonin 9mg PO QHS insomnia

Metoprolol Succinate 100mg PO daily

Polyethylene Glycol 3350 powder 1 packet

Senna 8.6mg PO QHS

Lisinopril 40 mg PO Daily

Allergies:

Patient reports no allergies

 Family Hx:

Father – deceased at 45 due to unknown causes

Mother- deceased at 60 due to a MI

Son- 45, alive and well.

No family hx of DM or cancer.

Social Hx:

Mr JS  is a widowed male who has lived at home with his son since his wife passed away 10 years ago. He is a Vietnam Combat Veteran. He rents an apartment with his son.  However, the owner is trying to vacate the apartment which is why the resident wants to leave VA to ensure the apartment is not vacated. He has been  residing at St. Albans VA since 02/2022. 

Habits- Reports using alcohol prior to being admitted to VA and smoking about 1 pack per day for 30 years but quit smoking about 15 years ago.

Travel- Pt denies travel

Diet- Pt. is on a low sodium diet and tries to avoid saturated fats.

Exercise:  Prior to his admission he would try to go for walks.

Safety measures – Admits to always wearing a seat belt.

Sexual Hx – Pt has not been sexually active in the past 10 years.

ROS:

General: Pt denies night sweats, recent weight gain or loss, loss of appetite.

Skin, Hair, Nails: Denies change in texture, excessive dryness, sweating, rashes/moles, discolorations, or pruritis. 

Head: Denies headache, vertigo, recent head trauma, or any loss of consciousness.

Eyes: Denies photophobia, fatigue, pruritus, excessive lacrimation, dryness.

Ears: Denies deafness, tinnitus.  

Nose/sinuses: Denies discharge, epistaxis or obstruction.

Mouth and throat: Denies sore throat, sore tongue, mouth ulcers. 

Neck: Denies localized swelling/lumps or stiffness/decreased range of motion. 

Pulmonary System: Denies dyspnea, shortness of breath, wheezing, hemoptysis, cyanosis, orthopnea or PND. 

Cardiovascular System: Denies chest pain, palpitations, irregular heartbeat, edema/swelling of ankles or feet, or syncope. 

Gastrointestinal System: Admits to chronic constipation. Pt states that he usually has a bowel movement every other day but he must strain himself to do so. Denies intolerance to foods, pyrosis, excessive flatulence, eructation, jaundice, diarrhea, rectal bleeding, or hematochezia

Genitourinary: Denies incontinence and dribbling. Patient states that “once in a while” he urinates a “small amount” without realizing, but that this does not interfere with his daily function or awaken him at night. Pt denies any change in urinary frequency, urgency, or urine color, oliguria, dysuria, polyuria.

Musculoskeletal System: Denies muscle/joint pain, deformity or swelling, redness or arthritis.

Peripheral Vascular System: Denies intermittent claudication, coldness, varicose veins, any swelling of extremities (besides left hip), or color change. 

Hematologic System: denies anemia, easy bruising or bleeding, lymph node enlargement or history of DVT/PE. 

Endocrine System: Denies polydipsia, polyphagia, polyuria, heat or cold intolerance, goiter or hirsutism. 

Nervous System: Denies seizures, loss of consciousness, sensory disturbances (numbness, paresthesia, dysesthesia, hyperesthesia), ataxia, loss of strength, changes in cognition/mental status/memory or weakness, headaches, vertigo.

Psychiatric: Pt admits to feeling “down” since his wife passed away 10 years ago. Pt states that “sometimes” he feels alone but denies any suicidal thoughts.

MSE: 23/25

Orientation:

Orientated- answers 2022, Fall season, 09/23, New York, St. Albans, VA, 3rd floor

Registration:

Lion, Apple, Tree was repeated

Attention and Calculation

WORLD was spelled backwards but slowly and missed the letter L

Recall

Lion, Apple, Tree were repeated

Language

Name a pencil and watch

Repeated “No ifs, ands, or buts”

Followed the command of taking a paper in his hand, folded in half and put it on the floor

He read “close your eyes: and obeyed it

He wrote “My name is BOB”

He was not able to copy the design

MSE

Appearance: appears stated age, makes eye contact, attentive and answers questions appropriately

Motor: not agitated or catatonic, no abnormal movements

Speech: Rate is slightly fast as the patient is talking fast and speaks mainly about  how he needs to be discharged to save his apartment

Affect: stable, range, intensity within normal limits

Thought content: denies any suicidal/ homicidal ideation, phobias, delusions, magical ideation

Thought process – impaired as patient  rambles  on about how he needs to go home; save his apartment and sue the landlord for trying to kick a veteran out. Tangential speech

Perception:No hallucinations, derealization

Intellect: average

Insight: aware of illness as he understands he needs to take certain medication to be better and that he needs to be on a wheelchair to avoid falls.

Physical Exam:

Vitals:

Temperature: 97.9 F (oral)

Heart Rate: 72, regular

SpO2: 98% on RA

Respiratory rate: 18 unlabored

Blood pressure: 122/76 right arm seated on wheelchair after the morning HTN dose

Weight (kg): 181.5 lbs

Height: 5”8

BMI: 27.5

Significant Physical Findings:

VS:

DATE/TIME         TEMP     PULSE    RESP     BP       PAIN     WEIGHT

09/3/22 @ 0900      98       58                124/84

Weights:

186.5 Lbs 09/1/2022

181.5 Lbs 08/11/2022

187.0 Lbs 07/31/2022

General: Alert, awake and oriented to person, place and time. Not in acute distress. Seated in a wheelchair.

Skin: Warm and moist. No scars or lesions noted.  Good skin turgor

Hair: Average quantity and distribution. 

Head: Normocephalic, atraumatic, no deformities.

Eyes: PERRLA, sclera white, conjunctiva clear, no eye discharge, EOM intact w/ no nystagmus. Visual acuity with glasses 20/20 OU.

Ears: Symmetrical and appropriate in size.  No lesions, masses, trauma on external ears.  No discharge, foreign bodies in external auditory canals  AU. Small quantity of non-impacted cerumen in auditory canals AU. TM’s pearly white, intact, and light reflex in appropriate position AU.  Auditory acuity intact bilaterally to whisper test.

Nose/Sinuses : No masses, lesions or discharge noted. Nares patent bilaterally. Nasal mucosa pink and well hydrated. Septum midline.

Mouth/Pharynx: Lips pink and moist. Mucosa pink and well hydrated. No masses or lesions. Palate pink and well hydrated. Palate and uvula rise with phonation.Good dentition.Gingiva pink and without any swelling.Tongue pink and does not deviate. Oropharynx well hydrated, no exudate. 

Neck:  Trachea midline. 2+ carotid pulses w/ no bruits appreciated. No adenopathy appreciated.

Thyroid: Non-tender, no palpable masses, no thyromegaly, no bruits noted.

Chest: Rises symmetrical, respirations unlabored. Lat to AP diameter 2:1. Non-tender to palpation. 

Lungs: clear to auscultation bilaterally, no adventitious lung sounds, lung sounds resonant over all fields to percussion

Heart: S1 and S2 present. Regular rate and rhythm. No murmurs noted. No S3 or S4, no friction rub. No thrills or heaves appreciated. PMI is noted at the midclavicular line, in the fifth intercostal space.

Abdomen: Abdomen symmetric and non-distended. No scars, striae, or pulsations noted. Bowel sounds are normoactive in all 4 quadrants. No aortic, renal, iliac, femoral bruits noted. No evidence of guarding, rebound tenderness, CVA tenderness or hepatosplenomegaly to palpation. Musculoskeletal: Neck, Trunk, Upper extremities, and Lower extremities : Appropriate range of motion of and no joint swelling. No Cogwheel rigidity.

Left lower Extremity: ⅘ strength Left Upper extremity: ⅘ strength  5/5 strength on all other extremities.  Weaker contraction against weight.  Decreased strength on the left extremity compared to the right extremity.

Ankles with no erythema or swelling and with appropriate range of motion including inversion, eversion, dorsiflexion, and plantarflexion.

Peripheral Vascular:  Mild edema above the mid calf  compression stockings.  The extremities are normal in color, size, and temperature.  Pulses are 2+ bilaterally in upper and lower extremities. No clubbing. No cyanosis. Capillary refill <2 seconds in upper and lower extremities. No ulcerations noted.

Neuro: Other than the left hip, patient has Full active and passive ROM of all extremities without rigidity or spasticity.  Inversion, eversion, dorsiflexion, and plantarflexion of ankle intact. Symmetric muscle bulk with good tone. No atrophy, tics, tremors or fasciculation. Strength 5/5 throughout.   Unable to test with Rhomberg, gait, or balance due to hip injury. Coordination by rapid alternating movement and point to point intact bilaterally, no asterixis.

Sensation intact to light touch, sharp/dull, and vibratory sense throughout.   Proprioception, point localization, extinction, stereognosis, and graphesthesia intact bilaterally. Reflexes intact bilaterally throughout 

Cranial nerves I-XII grossly intact.

I – Intact no anosmia.

II- VA 20/20 bilaterally. Visual fields full of confrontation. No AV nicking or papilledema noted.

III-IV-VI- PERRLA, EOM intact without nystagmus. No eye deviation noted

V- Facial sensation intact

VII- Facial movements symmetrical

VIII- Auditory acuity intact bilaterally to whisper test and during conversation with patient.

IX-X-XII- Swallowing and gag reflex intact. Uvula elevates midline. Tongue movement intact.

XI- Shoulder shrug intact. Sternocleidomastoid and trapezius muscles are strong.

Recent labs:

SLT – Lab Tests Selected

Collection DT     Specimen   Test Name          Result    Units       Ref Range

08/16/2022 11:57  BLOOD      WBC                   4.4 L  K/uL       4.5 – 11.0

08/16/2022 11:57  BLOOD      RBC                  3.97 L  M/uL       4.5 – 6

08/16/2022 11:57  BLOOD      HEMOGLOBIN           12.3 L  g/dL        13 – 18

08/16/2022 11:57  BLOOD      HCT                  38.2 L  %           40 – 52

08/16/2022 11:57  BLOOD      MCV                  96.2 H  fL          80 – 95

08/16/2022 11:57  BLOOD      MCH                  31.0    pg          27 – 33

08/16/2022 11:57  BLOOD      MCHC                 32.2    g/dL        32 – 36

08/16/2022 11:57  BLOOD      PLT                   233    K/uL       150 – 450

08/16/2022 11:57  BLOOD      MPV                  12.2 H  fL         7.5 – 10.5

08/16/2022 11:57  BLOOD      RDW                  13.4     %        11.5 – 14.5

08/16/2022 11:57  BLOOD      LYMPHOCYTE% (AUTO    25.4     %          20 – 50

08/16/2022 11:57  BLOOD      MONOCYTE%(AUTO)       9.4     %           2 – 12

08/16/2022 11:57  BLOOD      GRANULOCYTE% (AUT    63.6     %          42 – 75

08/16/2022 11:57  BLOOD      MONOCYTE(AUTO)       0.41    K/uL        .1 – .6

08/16/2022 11:57  BLOOD      LYMPHOCYTE (AUTO)     1.1 L  K/uL       1.2 – 3.5

08/16/2022 11:57  BLOOD      GRANULOCYTE (AUTO     2.8    K/uL       1.5 – 7.5

08/16/2022 11:57  BLOOD      EOSINOPHIL% (AUTO     1.1     %           0 – 7

08/16/2022 11:57  BLOOD      EOSINOPHIL (AUTO)    0.05    K/uL       0.0 – 0.7

08/16/2022 11:57  BLOOD      BASOPHIL% (AUTO)      0.5     %           0 – 3

08/16/2022 11:57  BLOOD      BASOPHIL (AUTO)      0.02    K/uL       0.0 – 0.2

SLT – Lab Tests Selected

Collection DT     Specimen   Test Name          Result    Units       Ref Range

08/16/2022 11:57  SERUM      CREATININE            1.0    mg/dl      0.4 – 1.2

08/16/2022 11:57  SERUM      UREA NITROGEN          17    mg/dl        6 – 22

08/16/2022 11:57  SERUM      GLUCOSE               100    mg/dl       65 – 115

08/16/2022 11:57  SERUM      SODIUM                139    mmol/L     135 – 145

08/16/2022 11:57  SERUM      POTASSIUM             4.7    mmol/L     3.5 – 5.0

08/16/2022 11:57  SERUM      CHLORIDE              103    mmol/L     100 – 110

08/16/2022 11:57  SERUM      CO2              26.7        mmol/L      24 – 32

08/16/2022 11:57  SERUM      CALCIUM               8.5    mg/dl      8.4 – 10.2

08/16/2022 11:57  SERUM      ANION GAP             9.3    mmol/L       3 – 11

08/16/2022 11:57  SERUM      EGFR                   94    ml/min     Ref: >=60

Comment: HEMOLYZED,SUGGEST REPEAT SPECIMEN AS RESULTS MAY BE INACCURATE.

Comment: specimen is slightly hemolyzed

LIPID Coll. date       CHOL    TRIG    HDL     LDL

8/16/22 06:00          113 L   55      38      64   55

2/29/22 06:00          122 L   65      38

HEMOGLOBIN A1C (NEW)       08/16/21 16:00     4.8

Assessment:

73 y/o male admitted to VA St Albans  for dementia LTC; hx of multiple PEs,HTN, HLD, aortic aneurysm(5.1 cm), GERD, CAD, PTSD, Parkinsonism, medication non-compliance, generalized muscle weakness and cognitive decline s/p  recent acute hospitalizations.His BP is currently well controlled on Metoprolol, and a no-salt diet with a systolic range of 120-134 and a diastolic range of 72-80.  Patient’s HLD is well controlled with atorvastatin as his most recent Lipid panel taken showed his LDL, HDL, total cholesterol, and Triglycerides to be within normal limits. His constipation is better with polyethylene glycol as bowel movements have been more regular.   Mental status exam significant for increased rate and

CVA w/hemiparesis; PEs with last PE in 2018.

MRI with suspected small lacunar infarct bilateral ganglia with muscle weakness left>right. Left upper extremity and lower extremity weaker than left but otherwise  Patient denies any sudden numbness or weakness. He is able to speak and understand. Patient was recommended to take Apixaban by neurology and physical therapy as tolerated. Patient has been compliant with this medication. Denies any alarm symptoms related to PE or CVA such as SOB, decreased strength on one side that is new, numbness, tingling.

Dementia

Alzheimers

Depression

Patient with gradual loss of memory.  Had these things but not currently. Physical exam with cogwheeling and bradykinesia during his stay at VA Manhattan  which is consistent with Alzheimers. Currently, no cogwheel rigidity or masked facies.  The patient is dependent on most of his ADLs and IADLS. Neurocognitive eval was done and recommended Aricept which the patient is non compliant with. He states he does not require this “ unnecessary medicine” . Resident states his depressed mood changes often and depends on the day. He sometimes recalls his wife and gets very sad. However, if he tries to keep himself busy with watching TV or reading books he does not feel depressed. His  adult niece also visits and is supportive which helps him feel better. States he does need to take any antidepressants.  Neuro follow up

CAD

Hypertension

Blood pressure has been well controlled. Patient is currently compliant with the blood pressure regimen of  lisinopril and metoprolol. His blood pressure was 124/84. It has ranged from 110s-140s over last few months. If he is non compliant the blood pressure usually increases. Encouraged a no added salt diet to help keep the blood pressure in control.

Hyperlipidemia

Lipids were last checked on 08/16/22 which showed within normal limit values. Patient has been compliant with lipitor 40 mg daily and advised to continue the medications. Encouraged a low saturated fat diet.

Aneurysm, ascending thoracic aorta,

Patient states he is aware he has an aneurysm  maximal cross-sectional diameter measuring 5.1 cm. However, he refuses further testing or surgery.

GERD; currently asymptomatic

Patient does not have current complaints about GERD. However, Famotidine PRN is ordered.

Supplements–Resident declines

Resident states his diet includes all the required nutrients and does not need to take supplements.

Constipation

Patient reports currently not taking Miralax as he has been having regular BM daily. Last BM was last night which was soft and not hard. Monitor.

 Pneumococcal Conjugate Vaccine (PCV15/PCV20):

 The patient declines to receive the recommended dose of pneumococcal  conjugate vaccine.

Influenza Immunization:

The patient declines to receive the recommended dose of seasonal influenza vaccine.

Herpes Zoster (Shingles) Vaccine:

The patient declines to receive the herpes zoster vaccine.