Identifying Data:

Name: Mr. H

Sex: Male

Address: New York

Date of Birth: 71 years old

Date & Time: 4/5/21, 2:00 PM

Location: New York Presbyterian Queens Hospital Internal Medicine Unit

Marital Status: Married

Religion: Muslim

Race: Indian

Source of Information: Wife

Reliability: Not fully reliable

Source of Referral: Son

Mode of Transport: Ambulance

Chief Complaint: “I am dizzy” x 3 days

History of Present Illness:

Mr. H is a 71 y/o married Indian male with a history of Alzheimer’s dementia with psychosis, hypertension, hyperlipidemia, DM, BPH, and iron-deficiency anemia, who presented to the NYPQ ED on 4/4/21 complaining of dizziness and slurred speech. He originally presented to the ED with these symptoms, accompanied by his wife. As per patient, he has been having dizziness and slurred speech for the past few months, on and off, and went to the supermarket today and felt extreme dizziness, described as “the room spinning.” Patient denied taking any medication for the dizziness, and denied any aggravating or alleviating factors. Patient did not seem to be a reliable historian. As per the family, patient complained of “not feeling well” in the morning and shortly thereafter had a brief unresponsive episode while leaning over the kitchen sink, lasting about 30 seconds, and then began acting confused. In the ER, patient was ambulatory but was leaning towards the right, with right facial droop and twitching. Patient denies numbness, weakness, tingling, current slurred speech, aphasia, headache, ear pain, or tinnitus. Patient scored a 1 on NIH stroke scale for mild facial palsy), but was still admitted to internal medicine unit to rule out stroke. CT head showed no acute infarction, intracranial hemorrhage, or mass effect. Labs and MRI ordered, as well as telemetry, TTE. Allowed permissive hypertension.

Currently, patient appears slightly agitated, refusing telemetry. Wife states he is agitated due to missing his psychiatric medications, which were non-formulatory and were not able to be given, so she brought them in and will be given shortly. Patient states he feels well and slept well last night. Denies current dizziness, slurred speech, numbness, weakness, LOC, or headache.

Past Medical History:

Present medical illnesses – Alzheimer’s dementia with Psychosis, Hypertension, Diabetes Mellitus, BPH, Iron-deficiency anemia

Childhood illnesses – none

Immunizations – Up to date

Screening Tests- none

Blood Transfusions- none

Past Surgical History: none

Medications:

1. Insulin Lispro (Humalog) sliding scale, subcutaneous injection, before meals, for DM
2. Doxazosin Mesylate 2 mg, oral, qd, for BPH and hypertension
3. Aspirin 81 mg, PO, qd, for cardiovascular event prophylaxis
4. Atorvastatin 10 mg, PO, qhs, for HLD
5. Rivastigmine 9.5 mg, transdermal patch, qd, for Alzheimers dementia
6. Amitriptyline 25 mg, PO, qhs, for dementia related psychosis
7. Carbamezapine XR, 500 mg, PO, qd, for dementia related psychosis
8. Clonazepam 1 mg, PO, qd, for dementia related psychosis
9. Quetiapine 25 mg, PO, qd, for dementia related psychosis

Patient reported he is compliant with medications

Allergies:

No known food, drug, or environmental allergies.

Family History:

Father- deceased at age 81, heart disease

Mother- deceased at age 87, unknown cause

Son- 42, alive and well

Son-40, alive and well

Maternal/Paternal Grandparents – Deceased at unknown age and unknown reasons

Social History:

Mr. H is a married male. He is retired, living at home with his wife.

Habits- Denies past and present use of alcohol, cigarettes, tobacco, e-cigarettes, illicit drug use, and history of substance abuse.

Travel- Denies any recent travel.

Safety- Admits to wearing seat belt.

Sleep – Admits to sleeping well, for about 8 hours every night.

Exercise – States that he takes walks for about 30 minutes every day.

Diet- Patients maintains a balanced diet, eats oatmeal for breakfast, salad with a protein for lunch, chicken or meat for dinner.

Sexual History: Heterosexual, monogamous. Currently not sexually active. Denies history of sexually transmitted infections.

Activities of Daily Living: Independent

Instrumental Activities of Daily Living: Has help from wife and sons

Advanced Directives: Full Code

Review of Systems:

General –Admits to generalized weakness and fatigue. Denies loss of appetite, recent weight loss or gain, fever, chills, 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 – Admits to dizziness and period of unconsciousness. Denies headaches, vertigo, head trauma, head fracture or coma.

Eyes –Denies use of glasses, contacts, visual disturbances, fatigue, lacrimation, photophobia, and pruritus.

Ears –Denies deafness, tinnitus, pain, discharge, or use of hearing aids.

Nose/sinuses – Denies discharge, obstruction or epistaxis.

Mouth/throat –Denies dentures, bleeding gums, sore throat, sore tongue, mouth ulcers, voice changes.

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

Breast- Denies lumps, nipple discharge, and pain.

Pulmonary system – Admits to shortness of breath and dyspnea on exertion. Denies cough, wheezing, orthopnea, paroxysmal nocturnal dyspnea, cyanosis or hemoptysis.

Cardiovascular system –Denies hypertension, chest pain, palpitations, edema/ swelling of the ankles/feet, irregular heartbeat, syncope or known heart murmur.

Gastrointestinal system –Denies changes in appetite, intolerance to foods, abdominal pain, diarrhea, constipation, nausea and vomiting, dysphagia, pyrosis, flatulence, eructation, jaundice, hemorrhoids, rectal bleeding, or blood in stool.

Genitourinary system –Denies urinary frequency, urgency, polyuria, oliguria, nocturia, incontinence, dysuria, hesitancy, dribbling, or flank pain.

Musculoskeletal system – Denies muscle/joint pain, deformity or swelling, redness or arthritis.

Nervous System– Admits to loss of consciousness, change in cognition / mental status / memory. Denies seizures, sensory disturbances such as numbness, paresthesia, dysesthesias, hyperesthesia, ataxia, loss of strength, or asymmetric weakness.

Peripheral vascular system –  Denies intermittent claudication, coldness or trophic changes, varicose veins, peripheral edema or color changes.

Hematological system – Admits to diagnosis of anemia 5 years ago.  Denies easy bruising or bleeding, lymph node enlargement, or history of DVT/PE.

Endocrine system –Denies polyuria, polyphagia, polydipsia, heat or cold intolerance, excessive sweating, hirsutism, or goiter.

Psychiatric –Admits to psychosis as result of dementia. Denies anxiety, depression/sadness, OCD or ever seeing a mental health professional.

Physical Exam

General: 71 year old male, alert and oriented to person, less oriented to place and time. Patient has good posture, is well dressed, well groomed, has good hygiene, and appears stated age. Patient appears very distressed, does not want to be here.

Vital Signs:      BP: 130/92

R: 18 breaths/min unlabored     

P: 86 beats/min, regular       

T:97.3 degrees F (oral)                      

O2 Sat: 99% on Room air

Height: 70 inches               Weight: 170 pounds        BMI: 24.4

Skin- Warm and dry, smooth, decreased turgor, nonicteric, no lesions, masses, scars, tattoos, thicknesses or opacities.

Hair- average quantity and distribution. Coarse, no lice or seborrhea noted.

Nails- Normal color size and shape of the nails. No spooning, clubbing, beau’s lines fissures, paronychia noted. Capillary refill <2 seconds throughout hands and toes.

Head-Atraumatic, normocephalic. Nontender to palpation on the frontal, temporal, occipital, and parietal areas. No deformities or specific faces noted. Some facial and lip twitching noted bilaterally.

Eyes-Symmetrical OU. Eyebrows and eyelashes even distribution, eyelids have no discharge or swelling, lacrimal glands have no excessive tearing, dryness, enlargement or erythema, lacrimal sac not inflamed or swollen. No evidence strabismus, exophthalmos or ptosis. Sclera white, conjunctiva and cornea clear. Visual fields full OU. PERRL, EOMs intact with no nystagmus. 

Ears- Symmetrical and normal size. No lesions, masses or trauma on external ears. No discharge/foreign bodies in external auditory canals AU. Tympanic membrane pearly white/intact with cone of light in normal position AU. Auditory acuity intact to whispered voice AU.

Nose-Symmetrical, no masses lesions or deformities, trauma or discharge. Nares patent bilaterally, nasal mucosa pink & well hydrated.

Sinuses- Non-tender to palpation and percussion over bilateral frontal and maxillary sinuses. 

Mouth

Lips – Pink, moist; no cyanosis or lesions.

Mucosa – Pink; well hydrated. No masses; lesions noted. No leukoplakia.

Palate – Pink, well hydrated. Palate intact with no lesions; masses; scars.

Teeth – Good dentition and no obvious dental caries noted.

Gingivae – Pink; moist. No hyperplasia; masses; lesions; erythema or discharge.

Tongue – Pink; well papillated; no masses, lesions or deviation noted. Non-tender to palpation.

Oropharynx – Well hydrated; no injection; exudate; masses; lesions; foreign bodies. Tonsils present with no injection or exudate. Uvula pink, no edema, lesions. 

Neck – Trachea midline. No masses; lesions; scars; pulsations noted. Supple; non-tender to palpation.  

Thyroid- Non-tender; no palpable masses; no thyromegaly.

Chest – Symmetrical, no deformities, no evidence of trauma. Respirations are unlabored, no paradoxical respirations or use of accessory muscles noted. Lat to AP diameter 2:1. Non- tender to palpation. 

Lungs – Clear to auscultation and percussion bilaterally. Chest expansion and diaphragmatic excursion symmetrical. Tactile fremitus intact throughout. No adventitious sounds. 

Abdomen-Abdomen flat and symmetric with some striae, and 2 scars from previous surgeries. No pulsations noted. Bowel sounds hyperactive in all four quadrants with no aortic/renal/iliac or femoral bruits. Tender to palpation throughout the right and left lower quadrants, tympanic throughout, no guarding or rebound noted. No hepatosplenomegaly to palpation, no CVA tenderness appreciated. 

Heart-Sinus tachycardia, normal rhythm. S1 and S2 are distinct with no murmurs, S3 or S4. No splitting of S2 or friction rubs appreciated. 

Mental Status Exam- patient is awake, alert, oriented and attentive. Mild right facial droop, no slurred speech or aphasia. Appears to be in agitated mood, has basic but incomplete comprehension and insight into his medical problems. Memory and cognitive ability partially intact, unreliable historian, needed help of family.

Peripheral Nervous System-

Motor/Cerebellar- Gait slightly unsteady, no ataxia. Tandem walking and hopping show balance not fully intact, leaning towards right. Full active/passive ROM of all extremities. Moderate symmetric muscle bulk, slight atrophy, with slight dyskinesia, tremors and fasciculation. Strength 5/5 throughout.  Romberg negative, no pronator drift noted.

Peripheral Vascular Exam- Skin normal in color and warm to touch upper and lower extremities bilaterally.  No calf tenderness bilaterally, equal in circumference.  Homan’s sign not present bilaterally. No palpable cords or varicose veins bilaterally. No palpable inguinal or epitrochlear adenopathy. No cyanosis, clubbing / edema noted bilaterally.

Musculoskeletal: No soft tissue swelling / erythema / ecchymosis / atrophy / or deformities in bilateral upper and lower extremities. Non-tender to palpation / no crepitus noted throughout. Full Range of Motion of all upper and lower extremities bilaterally.  No evidence of spinal deformities.  

Assessment – Mr. H is a slightly reliable, 71 y/o married Indian male with a history of Alzheimer’s dementia with psychosis, hypertension, DM, BPH, and iron-deficiency anemia, who presented to the internal medicine unit with dizziness and slurred speech.

Labs:

Chemistries

Na- 140

K- 5.2

Cl- 104

Co2- 26

BUN- 40.3

Creatinine- 2.05

BUN/CR ratio- 20

Calcium- 8.7

Magnesium- 1.9

Glucose- 77

Iron Level- 56

Iron Binding Capacity- 256

Iron Saturation- 22

Transferrin- 197

Folate- 13.1

Hematology:

WBC- 8.52

Platelets- 221

Hemoglobin– 10.7

Hematocrit- 35.1

Mean Cell Hemoglobin Concentration- 30.7

RBC Count-4.35

Liver Function Tests:

Protein- 7.1

Albumin- 4.6

Alkaline Phosphatase- 150

AST- 14

Bilirubin total- .1

Imaging:

EKG- sinus rhythm, within normal limits, no abnormalities- HR- 79 bpm, PR interval- 168 ms, QRS duration- 84 ms, QT interval- 366 ms, QTc-399 ms, P-axis-67, QRS axis-52

Chest X-ray- no focal consolidations or pleural effusions, no evidence of pneumothorax, cardiomedastinal silhouette unremarkable

CT head- no acute territorial infarction, intracranial hemorrhage, or mass effect. Mild chronic microvascular ischemic disease.

MRI Brain Without Contrast- mild/moderate small vessel ischemic changes, no acute infarcts, hemorrhage, or masses

MRA Neck Without Contrast- unremarkable, no significant stenosis involving the common or internal carotid arteries, unremarkable vertebral arteries.

Transthoracic Echocardiogram-normal left ventricular size, wall thickness, wall motion, systolic function, estimated EF- 65%, normal RV size and function, normal size atria , no significant valvular abnormalities

Plan:

Problem List:

1. Dizziness, right facial droop and leaning towards right when ambulating- rule out stroke- head CT, MRI, labs, telemetry, TTE, allow permissive HTN, neuro check q4 hours
2. Alzheimer’s Dementia – continue administering Rivastigmine
3. Dementia related Psychosis-continue administering home psychiatric medication, QT interval/ QTc not prolonged on EKG (366/ 399 ms)
4. Dyskinesia, facial twitching from psychiatric medications at baseline- rule out stroke
5. Acute Kidney Injury- BUN 43.8, Cr 2.05- per wife, patient has stage 3 CKD at baseline- control with hydration, trend creatinine, follow up renal US and UA
6. Diabetes Mellitus- monitor fingerstick, continue insulin, follow up HA1c
7. Iron Deficiency Anemia- H/H 9.9/33.4- monitor H/H and keep T&S, follow up anemia panel
8. Hypertension/ Hyperlipidemia- continue administering aspirin and atorvastatin. BP medication on hold to maintain permissive htn, follow up lipid panel
9. BPH- continue administering Doxazosin

Differential Diagnoses

1. Stroke- dizzy, right facial droop, leaning towards right when ambulating. However, CT and MRI did not show signs of any acute infarct.
2. Seizure-felt dizzy and then lost consciousness. However, no sign of abnormalities that could cause seizures on CT or MRI, no h/o of seizures
3. Heart Arrhythmia- dizziness x a few weeks. However, refused Telemetry, no sign of arrhythmia on EKG
4. AMI- dizziness. However, no chest pain, cardiac enzymes negative.
5. Pulmonary Embolism-dizziness. However, no sign of PE on CXR, CTPA not done
6. Neurological Condition- such as Parkinson’s Disease- dizziness could be an early sign. Also has dementia, noted some tremor/ involuntary movements.
7. Iron Deficiency Anemia-can cause dizziness, H/H was low (9.9/33.4), low Iron level and RBC count, dizziness has been going on for a few weeks
8. Polypharmacy- is on multiple medications that could cause dizziness, including amitryptilline, rivastigmine, doxazosin, clonazepam, and quetiapine.