Posted at 12.14.2018
History of Present Disease: Mr. AS can be an 85 time old Caucasian man with a previous history of hypertension and torso pain who currently reveals to us with dementia and complaints of being unsure of how he received here. Our patient was diagnosed with hypertension at the age of 40 and developed chest pain at the age of 45 when he was advised he needed a tempo maker. The pace maker was placed and he has already established no heart issues since that time. At the age of 55 our patient was diagnosed with dementia which he resided with separately at home until two years ago when he previously a heart stroke. He was accepted to ALF on Apr 28, 2009 where he was told that he previously a stroke and could not walk. Mr. AS has been residing at the service since entrance. Our patient currently denies any upper body pain, head aches or vision changes. Mr. AS will complain of a cough that becomes successful at times with clear sputum. He quit smoking twenty years before and has a 160 load up year history. He also suggests that he believes he hears himself wheezing sometimes. Mr. AS says that his legs don't allow him to walk any more and that the exercises that are finished with the walker harm his arms. He says that he has sense in his thighs but that activity is the challenge. Mr. AS explained through the interview that he has accepted the actual fact that he'll not have the ability to walk again which he is quite happy with his life so long as he can breathe and discuss. Our patient also mentioned that he has problems keeping in mind recent occasions and is way better at remembering incidents that took place during his youth.
No known allergies
Mr. AS is not hitched and has a partner who lives in Miami Beach that once in a while visits the service. Our patient is not sexually active, does not consume alcohol, does not use levels of caffeine and denies any illicit drug use. Our patient stopped smoking twenty years earlier and has a 160 pack year record. Mr AS during his free time at ALF makes clocks as items for his friends and workers at ALF. He says that making clocks makes him happy and keeps him busy. Mr. AS is not on any special diet and eats everything that is offered to him.
General- Mr. AS feels generally well, he does not complain of tiredness, fever or pain anywhere presently. He also denies any cravings changes.
Skin- Mr. AS denies any epidermis staining, bruising or bleeding.
Head- Patient denies any problems or dizziness
Eyes- Patient claims that he has already established no change in his perspective, no blurry perspective.
Ears- Patient states that he can notice in his right ear canal however, not his left hearing. He has no ringing in the ears or earaches.
Nose/Throat/Mouth- Patient denies any rhinorrhea, dried up mouth or tooth ache. The patient complains of any tickling discomfort in his throat when he talks that makes him cough.
Respiratory- Patient complains of an coughing that is nonproductive but sometimes becomes profitable and produces a clear sputum. He also states that he hears himself wheezing sometimes which does not occur more at any particular time of your day.
Cardiovascular- Patient does not have upper body pain or palpitations. He also didn't complain of edema in his thighs.
Gastrointestinal- Patient has constipation and records having bowel motion once a month for the last twenty years. Patient denies vomiting after eating.
Genitourinary- Patient urinates 2-3 times per day and wears a diaper. Patient denies hematuria, polydipsia or polyuria.
Neruologic- Patient denies headaches and claims that he had a stroke 2 yrs ago. Because the stroke he has already established weakness in both hip and legs. He expresses that he has experience in both legs but that movement is difficult. See HPI
Musculoskeletal- Patient does not have any joint pain. Patient does complain of arm muscle pain because of the walker that he uses for physical remedy.
Endocrine- Patient denies any changes in thirst and denies any unintentional weight loss
Hematopoetic- Patient does not complain of bleeding or bruising
Psychiatric- Patient expresses that he has a memory problem and that he cannot bear in mind recent incidents but can remember more from his youth. Patient denies depression and the SIGECAPS questions were negative. The patient does not have any thoughts of suicide and denies fluctuating moods.
Vital Signs- Blood pressure 132/72 mmHg, Respiratory Rate 16 breaths/minute, Pulse rate 60 bpm, Temps afebrile to touch, BMI 29
General- Patient is well groomed, overweight and looks his stated age. He is cooperative and focused. He also will not appear to be in any severe distress.
Skin- A 2 cm wide circular shaped ulcer exists on the right ankle joint 1 cm above the medial malleolus. Another ulcer about 3 cm large and circular is present on the remaining shin about 6 cm from the tibial tuberosity. Your skin over the kept lower leg is erythematous and hot to touch set alongside the right calf.
HEENT- The head is normocephalic, no bumps scars or lesions present on the head. The conjunctiva are pink and well perfused and there are no signs or symptoms of icterus in the sclera. No papilledema visualized and no flame hemorrhages or a-v nicking observed. Nasal septum is midline, no dental ulcers discovered and the uvula and tongue were both midline. No indications of central or peripheral cyanosis. Reading greatly impaired in the still left ear. No release from either ear canal and no tenderness noted after palpation. Trachea is midline. The thyroid was non palpable. No bruits been told over carotid. Preauricular, posterior auricular, occipital, tonsillar, submaxillary, submental, anterior cervical, posterior cervical, supraclavicular, and infraclavicular lymph nodes are all nonpalpable. The individual was found to possess poor visual acuity and the sight were slow to respond to light. EOM were intact bilaterally.
Heart- No thrills were palpable in the aortic, pulmonic, tricuspid and mitral areas. Normal S1 and S2 listened to in every 4 areas. No murmurs or extra center sounds heard in all 4 areas of auscultation. No carotid bruits or distended jugular veins. The pulse rate was regular rhythm.
Lungs- Chest is symmetrical and the A:P is 2:1. Upon auscultation of anterior and posterior torso wall, the left lung field breathe tones were decreased in every lobes, the right lung field experienced wheezing present in all regions. Upon percussion there is normal resonance in the right lung in all locations but dullness in the still left lung in all regions. No accessory muscles were used for respiration. No crackles were listened to upon auscultation. The bilateral diaphragmatic excursion was 6 cm. Normal tactile and vocal fremitus.
Abdomen- Upon inspection from the base of the foundation, bulging flanks were present along with spider nevi. A scar tissue from a feeding tube exists in the right higher quadrant. There have been no bowel does sound and no bruits heard on the abdominal aorta, renal arteries, iliac arteries or femorals. Non palpable spleen and kidney. The liver edge was non palpable, and liver span was 6 cm. No masses or pulsations experienced after palpation, no guarding or rigidity in all quadrants. Normal tympanic audio heard after percussion in each quadrant. CVA tenderness absent bilaterally.
Extremeties- Dorsalis pedis pulse and posterior tibial pulse were 1+ bilaterally. Non pitting edema in ankles bilaterally. Radial pulses were present bilaterally and symmetrical 2+.
Musculoskeletal- Motor strength in higher extremities was 4/5 bilaterally and lower extremities were 3/5 bilaterally. Upper extremities unaggressive and active range of motion was full bilaterally. Lower extremities passive motion was full-range and active flexibility was limited.
Neurological- The patient was alert and focused. He could remember incidents that occurred years back but not recent events. He's alert to his memory loss and dementia. The facial skin was symmetrical, no drooping of the eye or lips, no drooling from the mouth area present. No relaxing tremor noted. Sharp and dreary discrimination in tact in lower extremities, and higher extremities and face. Poor finger to nose area. Biceps, triceps and brachioradialis reflexes are normal bilaterally. Patellar and Achilles reflex and gait could not be determined scheduled to physical restraints.
Glucose 122 mg/dL (70-105mg/dL)
Bun/Cr 1. 35 mg/dL (0. 7-1. 3mg/dL)
Dementia- The signs and symptoms of dementia look slowly but surely with the first indication usually being short term memory reduction. Dementia progresses in levels with early development presenting with storage and learning impairment. Changes in ambiance and terminology problems could also develop. The intermediate phase of dementia presents with the individual unable to remember new information and there's a loss of dependence during this stage scheduled to personality changes and failure to remember to consume, and bathe. During this period the patient is no longer focused to time and place and their structure of rest is disturbed which further aggravates their spirits. The later period of dementia results complete reliance on others for survival and the individual becomes not capable of learning and storage area formation and problems swallowing.
Our patient's current position places him at the start of the intermediate period of dementia. Mr. AS is unable to bear in mind new information; experiences sleep pattern changes, has mood swings and is also not capable of bathing himself. Mr. AS continues to be focused to time and place and was able to correctly status where he was, how much time he previously been there, and his identification evidently. Our patient is incapable of keeping in mind how he arrived to the service and the happenings before that point.
Diagnosis of dementia requires the existence of impairment of ram, both long and brief. The standards for dementia also includes: personality changes, and impairment of higher cortical function. These changes must also hinder the patient's lifestyle and must not happen only with delirium. Our patient satisfies all of the criteria for examination of dementia.
If the individual reaches all requirements for dementia, then the etiology should be established based on the annals and physical exam. Types of dementia include: alzehimer's, vascular, lewy body, frontotemporal and multi infarct dementia.
Alzheimer's dementia is the most common and patients normally present with storage problems, term finding difficulties and have a history of getting lost in familiar places. Alzheimer's dementia is a differential examination in our case due to lack of information from the family. After obtaining more background from the family about the development of the condition in this patient, we can make a definite identification. Our patient is unable to give us information on his status from before his heart stroke and therefore cannot provide information on the development.
Vascular type dementia is dementia occurring after a stroke or other cerebrovascular disease. Patients with vascular type of dementia usually present with neglect, aphasia, dyscalculia and apraxia. The family would need to be contacted in order to determine if the patient's dementia progressed further after the stroke and know what level he was at prior to the stroke.
Multi infarct dementia is dementia credited to numerous small strokes in the brain. The risk factors for this kind of dementia include: hypertension, atherosclerosis, smoking and stroke. Multi infarct dementia is a differential medical diagnosis scheduled to no understanding of strokes prior to the one two years in the past. A CT scan would be helpful in detecting past strokes.
Mr. AS happens to be on medication that is indicative of alzheimer's type of dementia which include: Mirtazapine 15mg PO QD for major depression, Namenda 10mg PO Bid for treatment of alzheimer's symptoms, Certavite antioxidant 18mg PO QD to prevent vitamin deficiency and undernutrion, Aricept 10mg PO QD for dementia associated with alzheimer's, and Zolpidem Tartrate 5mg PO QD for help sleeping. These medications cannot remedy alzheimer's but can decrease the progression; this is attained by cholinesterase inhibitors like Aricept which boost the acetylcholine levels in the brain to boost mental functions.
Chest pain- The individual currently will not complain of chest pain. Mr. AS has a pacemaker that was put 40 years back and claims that he hasn't had any complications since then. The cause of the torso pain cannot be dependant on the individual or the graph. Possible factors behind breasts pain include: heart attack, angina, aortic dissection, coronary spasm, pericarditis, gastroesophageal reflux, esophageal spasm, costochondritis, pulmonary embolism. Mr. AS's medication list includes medications for both angina and gastroesophageal disease. The medications are, Omeprazole 20mg PO Bet for gastroesophageal reflux, Nifedipine 90mg PO QD for treatment of hypertension and angina, and Metoprolol tartrate 25mg PO QD for treatment of hypertension and angina. He's also on aspirin for pain management. All medications should be prolonged.
Cough and wheezing- The patient currently complains of the coughing and wheezing. The patient stated that he remembers having asthma as an adult but this is not shown in the graph. Asthma is irritation of the airways that causes shortness of breathing, coughing and wheezing. The wheezing in asthma would present as bilateral and inside our case our patient's wheezing was only within the right lung field. Wheezing without asthma in our patient could be scheduled to a lung tumor. Mr. AS has a 160 pack year history placing him vulnerable to COPD, emphysema and a lung tumors. Lung tumors can develop and impinge on the bronchial tree which can cause one sided wheezing as is the case inside our patient.
Depression- Major depression is a common finding in patients with dementia. The patient currently does not present with depressive disorder and the SIGECAPS questions were negative. The patient doesn't have any thoughts of suicide and denies fluctuating moods. Mr. AS's current medication for despair should be extended, Mirtazapine 15mg PO QD for depression. His current medication functions by increasing the serotonin levels in the brain to assist with depression and it is showing its effects positively inside our patient.
Arm and calf weakness- Mr. AS happens to be receiving physical remedy at North Beach ALF for post stroke induced lower leg weakness. Our patient's stroke has affected the part of his brain that control buttons his leg motion. Mr. AS's top extremities are being worked on for further building up to compensate the weakness in his lower extremities from post heart stroke.
Preventative Drugs- A minuscule mental status exam should be performed to evaluate the progression of your patient's dementia. A colonoscopy and digital rectal exam should be performed to eliminate colon cancer and prostate cancer and hyperplasia which can be high risks in our patient human population. The pneumovax vaccine and flu shot should be achieved as routine precautionary measures in our patient. Our patient happens to be on Tamsulosin HCl 0. 4mg PO QD for benign prostatic hyperplasia. The patient's chart did not state any pervious diagnosis of benign prostate hyperplasia and really should be implemented up with an electronic rectal examination.
The patient's family should be contacted to obtain additional information on illnesses that run in the family such as tumor, heart disease, hypertension, diabetes mellitus, or emotional disorders. Information regarding Mr. AS's physical and mental status prior to admittance to the service will also have to be obtained from the family to asses any changes in mood, and mental status.
A CT scan and MRI of the mind should be ordered to imagine changes developing in cortical locations. An X-Ray should be ordered to visualize any pulmonary or cardiovascular changes such as a lung tumor or pulmonary edema. Pulmonary function checks should be performed to look for the type, obstructive or restrictive, of respiratory disease present in our patient.
All of Mr. AS's medication should be sustained and customized if new conclusions from imaging studies or pulmonary function exams are present. The patient must be checked with cbc, MRI scans and X-Ray. Monitoring of the blood sugar and Bun/Cr also needs to arise, if the degrees of these parameters are proven to increase then concern of drug-drug interactions and undesireable effects should happen and remodification of the current medication list should be done.