Identifying Data:

Name: Mr. M

Sex: Male

Address: Queens, NY

Date of Birth: 12/27/1939, 81 years old

Date & Time: 4/19/21, 2:15 PM

Location: New York Presbyterian Hospital, Queens, NY

Religion: Christian

Marital Status: Married

Race: Caucasian

Source of Information: Self

Reliability: Reliable

Source of Referral: Self, PCP: Dr. Pimentel

Mode of Transport: Ambulance

Chief Complaint: “I can’t stand up” x 1 day

History of Present Illness:

81 year old married Caucasian male who lives at home with his wife and is dependent on her help with ADLs/IADL’s, at baseline, ambulates with a cane around the house and with a walker when he goes for dialysis or to the supermarket, with PMH of Hypertension, ESRD on HD, CAD s/p CABG, and Open Angle Glaucoma, presents to ED on 4/16/21 for generalized weakness x 1 day, difficulty ambulating and SOB worsening. Patient missed one session of HD this week. He reports receiving the second dose of the Covid vaccine yesterday morning and lower extremity weakness and SOB began immediately afterwards, gradually worsening throughout the day. Patient states that he slept well through the night, but this morning, he woke up with worsening SOB and his legs felt so weak that he could not keep his balance and fell down immediately every time he tried to stand up, so he got concerned and came to the hospital. In the ED, he rated his SOB and weakness as a 9/10, stating it was constant with no aggravating or alleviating factors. Patient denies taking any medication to help with the SOB or weakness, denies decreased strength of extremities, chest pain, nausea, vomiting, fever, chills, abdominal pain, headaches, visual changes, paresthesia, diaphoresis, recent travel or trauma.

In ED, Patient was placed on BIPAP due to SOB, was admitted to the IM unit, and was sent for urgent dialysis. After dialysis, patient was breathing better so bipap was titrated, and then placed on nasal cannula. This morning, the nasal cannula was removed, and he has good O2 saturation on room air.

Today, patient feels much better after receiving his dialysis on Saturday and resting for a few days. Currently still admits to loss of balance and difficulty ambulating, stating that his knees feel weak since he requires bilateral knee implants. However, he is improving, and was able to take a few steps to the bathroom using a walker for the first time today. He denies any current SOB, dyspnea, dizziness, knee pain or decreased ROM, generalized weakness, chest pain, nausea, vomiting, fever, chills, abdominal pain, headaches, visual changes, paresthesia, diaphoresis.

Past Medical History:

Present medical illnesses – Hypertension, ESRD, CAD, Glaucoma

Past Illnesses- none

Childhood illnesses – none

Immunizations – Up to date

Screening Tests- none

Blood Transfusions- none

Past Surgical History:

CABG, 9/2018, for CAD, at NYPQ

Medications:

1. Amlodipine 10 mg, PO, 1 tablet QD, for hypertension
2. Carvedilol 25 mg, PO, 1 tablet BID, for CAD
3. Phoslo (Calcium Acetate) 667 mg, PO, 3 capsules TID with meals, for CKD
4. Folic Acid 1 mg, PO, 1 tablet QD, supplement
5. Latanoprost .005% ophthalmic solution, 1 drop to each eye, QHS, for Open Angle Glaucoma

Allergies:

No known food, drug, or environmental allergies.

Family History:

Mother – deceased at age 82, dementia

Father – deceased at 89, natural causes

Son- 59, Alive and Well

Son- 55, Alive and Well

Maternal/paternal grandparents – Deceased at unknown age and unknown reasons

Social History:

Mr. M is a married male, living at home in a first floor apartment with his wife. He uses a cane to walk around the house and a walker when he goes out. He is a retired gardener.

Habits – Patient drinks one cup of coffee a day. Admits to drinking 1 bottle of beer once in a while. Admits to past smoking 50 pk/yrs, quit 15 years ago. Denies use of e-cigarettes or any illicit drug use. 

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 does not regularly exercise or engage in physical activity.

Diet- Patients maintains a balanced diet, eats eggs in the morning, grilled cheese for lunch, and receives meals on wheels 4-6 ounce meal packages for dinner.

Sexual History: Monogamous, has single female partner. Currently sexually active. Denies history of sexually transmitted infections.

Advance Directives: Full Code

ADLs: Has difficulty, has help from wife

IADLs: Has difficulty, has help from wife and children

Review of Systems:

General – Denies loss of appetite, recent weight loss or gain, current generalized weakness, fatigue, 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 – Denies dizziness, headaches, vertigo or head trauma, unconsciousness, head fracture or coma.

Eyes –Patients admits to use of glasses, and Open Angle Glaucoma, which he uses eye drops for. Denies use of contacts, visual disturbances, fatigue, lacrimation, photophobia, and pruritus. Last eye exam last March- normal.

Ears –Admits to occasional tinnitus, slight decrease in hearing bilaterally, “able to hear 80%” and does not interfere with his quality of life. Denies ear pain, discharge, or use of hearing aids.

Nose/sinuses – Denies discharge, obstruction or epistaxis.

Mouth/throat – Admits to use of dentures for the past 20 years. Denies sore throat, sore tongue, bleeding gums, mouth ulcers, voice changes. Last dental exam 20 years ago. 

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

Breast- Denies lumps, nipple discharge, and pain.

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

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

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

Genitourinary system – Admits to oliguria due to ESRD. Deniesurinary frequency, urgency, polyuria, nocturia, incontinence, dysuria, hesitancy, dribbling, or flank pain.

Musculoskeletal system – Admits to arthritis, stiffness in knees. Denies muscle/joint pain, deformity or swelling, or redness.

Nervous System– Admits to some numbness and decreased sensation in bilateral knees. Denies seizures, loss of consciousness, ataxia, loss of strength, change in cognition / mental status / memory, or asymmetric weakness.

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, or history of DVT/PE.

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

Psychiatric –Admits to occasional depression/sadness over the past year as a result of being in the house due to COVID. Denies anxiety, OCD or ever seeing a mental health professional.

 Physical Exam

General: 81 year old male, alert and oriented to person, place and time. Patient is of average build and has good posture, is well dressed, well groomed, and has good hygiene. Patient appears in no apparent distress.

Vital Signs: BP: 146/68, supine                       

R: 17 breaths/min unlabored     

P:61 beats/min, regular       

T: 36.7 Degrees C (oral)                      

O2 Sat: 95% on Room air

Height: 71 inches                    Weight: 180 pounds               BMI: 25.1

Skin- Warm and dry, smooth, poor turgor, nonicteric, with fistula on left arm for dialysis placement. 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.

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 upon whisper test.

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 –Dry; no cyanosis or lesions

Mucosa – Pale. No masses; lesions noted. No leukoplakia.

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

Teeth – wears dentures. Was not wearing them during examination

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

Tongue – Pale, dry, well papillated; no masses, lesions or deviation noted.

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; no bruits noted.

Thorax & Lungs 

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. No adventitious sounds. 

Abdomen-Abdomen flat and symmetric with no striae, scars or pulsations noted. Bowel sounds normoactive in all four quadrants with no aortic/renal/iliac or femoral bruits. Abdomen soft and non-tender to palpation across all 4 quadrants, no guarding or rebound noted. No hepatosplenomegaly to palpation, no CVA tenderness appreciated. 

Heart-Normal rate and rhythm. S1 and S2 are distinct with no murmurs, S3 or S4. No splitting of S2 or friction rubs appreciated. Carotid pulses are 2+ bilaterally without bruits.

Male Genitalia- deferred

Anus, Rectum, and Prostate-deferred

Mental Status Exam- patient is alert, attentive, and oriented. Speech and language are clear and fluent with good word comprehension.. Appears to be in good mood, has insight and judgment in his medical problems. Memory and cognitive ability intact, gave accurate information upon assessment of history.

Cranial Nerve Exam – 

CNII-visual fields full by confrontation, red reflex present

CN III, IV, and VI- extraocular movements intact, PERRLA, no ptosis

CN V- face sensation intact bilaterally, corneal reflex intact, jaw muscles strong without atrophy

CN VII- facial expressions intact, clearly enunciates words

CN IX and X- no hoarseness, uvula midline with elevation of soft palate, gag reflex intact, no difficulty swallowing

CN XI- full range of motion at neck with 5/5 strength and strong shoulder shrug

CN XII- tongue midline without fasciculations, good tongue strength

Peripheral Nervous System-

Motor/Cerebellar-Full active/passive ROM of all extremities. Some rigidity and crepitus in knees with movement. Symmetric muscle bulk, slight atrophy, no tics, tremors or fasciculation. Strength 4/5 throughout upper extremities, 3/5 on lower extremities bilaterally.  Romberg negative, no pronator drift noted. Gait slightly unsteady, but steady with walker. Deferred tandem walking and hopping, because if unsteady without walker. Coordination by rapid alternating movement and point to point intact bilaterally, no asterixis.

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

Reflexes-2+ throughout.

Peripheral Vascular Exam- Skin normal in color and warm to touch upper and lower extremities bilaterally.  No calf tenderness bilaterally, equal in circumference, no edema. No palpable cords or varicose veins bilaterally. No palpable inguinal or epitrochlear adenopathy. No cyanosis, clubbing / edema noted bilaterally.

 Labs:

Chemistries:

Na- 138

K- 4.4

Cl- 97

CO2- 28

BUN- 46.6 (high)

Cr- 6.88 (high)

BUN/Cr Ratio- 7 (low)

Ca-8.8

Mg- 2.1

P- 3.8

Anion gap-12

Glucose- 100

Vitamin D Hydroxy- 28 (slightly low)

Liver Function Tests:

Protein-5.6

Albumin-3.6

Globulin- 2.0

AST- 14

ALT- 24

Alk Phos- 61

Bilirubin- .4

Cardiac Markers

Cholesterol Total- 145

Triglycerides- 146

LDL- 91

HDL-28 (low)

Chol/HDL Ratio- 5.2 (high)

Troponin- .153 (high)

Pro-BNP- >7000 on admission

Hematology

WBC-8.58

Hemoglobin-10.8 (slightly low- desired for CKD is at least 11)

Hematocrit- 32.8 (slightly low- desired for CKD is at least 33%)

Platelets-191

MCV- 93.7

MCH- 30.9

RBC- 3.5 (low)

HbA1c- 4.8

Imaging:

CXR- LUNGS/PLEURA: There is interval development of small left pleural effusion and bibasilar opacities which may represent atelectasis or consolidation. There is also mild central pulmonary vascular congestion. HEART/MEDIASTINUM: Stable cardiomegaly. Tortuous thoracic aorta.

TTE- Mild segmental left ventricular systolic dysfunction, estimated EF 40-45%, the basal to mid inferoseptal and inferior walls are akinetic, the right ventricle is normal in size, thickness and function. The aortic valve is sclerotic without stenosis, No aortic regurgitation, mitral valve is normal, mild mitral regurgitation. The inferior vena cava is > 2.1 cm and exhibits reduced respiratory variability consistent with a right atrial pressure of ~ 15 mm Hg. There is no pericardial effusion.

Assessment

81 year old married Caucasian male with history of Hypertension, ESRD on HD, CAD s/p CABG, and Glaucoma, presents to ED for generalized weakness, difficulty ambulating and SOB worsening. Patient was sent for urgent hemodialysis upon arrival to the hospital, which helped improve symptoms. Currently, not experiencing SOB, sating well (95%) on room air, still admits to loss of balance and difficulty ambulating, stating that his knees feel weak, but improving since original presentation. Was able to take a few steps to the bathroom using a walker for the first time today. 

Differential Diagnoses:

1. Fluid Overload due to missing HD- had SOB and very high pro-BNP, indicating acute CHF exacerbation, upon arrival. Pro-BNP was not rechecked, but symptoms improved following HD.
2. Weakness/ Anemia due to ESRD- has low h/h, got better after receiving dialysis
3. Knee Osteoarthritis-most common cause of OA. Admits to weakness, stiffness in knees, some crepitus upon movement, decreased mobility of knee, slightly decreased strength. However, no swelling, redness, or deformity, full ROM intact.
4. Rheumatoid Arthritis- has stiffness and weakness in knees, is symmetrical- affecting both knees. However, no swelling, pain, or redness, full ROM intact.
5. Anxiety/ Hyperventilation- symptoms began after receiving the vaccine, possibly nervous about receiving it. Unlikely because BNP was high and symptoms have been resolving since HD, so does not seem psychiatric.

Problem List/Plan – 

1. SOB/ CHF Exacerbation- likely from fluid overload due to missed dialysis. Pro-BNP was elevated>7000 on admission. Following dialysis, patient was breathing better. Limit Fluid intake, monitor on Tele, follow up Pro-BNP.

• Difficulty Ambulating/ Lower Extremity Weakness/ Unsteady Gait-Improving with Physical Therapy, continue PT. Orthopedic consult, consider xray/MRI to check for arthritis, ESR, CRP and Anti-CCP antibodies for RA.

• Post Covid vaccine weakness-improving, continue supportive care

• Elevated Troponin-.153, likely elevated due to ESRD, monitor trend x3, perform EKG to r/o ACS

• ESRD/HD – BUN, CR, and BUN/ CR ratio high, Fasting lipids mainly normal except low HDL, continue scheduled HD on Tuesdays, Thursdays and Saturdays, continue Phoslo, monitor electrolytes, consult nephrology, on list for kidney transplant.

•  Vit D deficiency- likely due to ESRD, prescribe supplemental Vitamin D 

• Low H/H and RBC’s- likely due to ESRD, continue monitoring to ensure it does not drop

• Tinnitus and slight hearing loss- likely due to aging, whisper test was normal, not interfering with QOL, no current intervention necessary

• HTN-Well-controlled, continue current medications

1. CAD-low HDL/ high Cholesterol/HDL ratio- no acute symptoms, encourage healthy eating habits, consider increasing dosage of CAD medications or adding new medication

1. Open Angle Glaucoma-Well-controlled, continue Latanoprost