Identifying Data

Full Name: A.M.

Sex: Male

DOB: xx/xx/1946

Date & Time: June 6, 2023 11:00 am

Location: Metropolitan Hospital Center

Religion: Unspecified

Source of Information: Self / daughter

Reliability: Reliable

Source of referral: Self

Mode of transportation: Walking

 

Chief Complaint: “Cough” x 1 month

 

History of Present Illness:

A. M. is a 79 y/o M independent in ADLs and ambulating freely with past medical history of type II Diabetes and benign prostate hyperplasia s/p TURP in 2016 presents to the geriatric outpatient clinic accompanied by daughter for transfer of care. Patient is originally from Guerrero, Mexico and immigrated to the US one month ago (May 2023). Patient states he immigrated to the U.S. to be closer to family. He is currently residing with his daughter (age 44), granddaughter (age 20) and great granddaughter (age 2) in NY, NY. As per daughter, patient was following with a doctor in Mexico who was treating him for diabetes, last visit was 6 months ago. Patient does not currently have any medical records from Mexico but states he will attempt to find them.

Patient reports he is active, can climb stairs and ambulate 10-15 blocks without stopping, denies SOB, chest pain, leg pain/cramping with ambulation. Patient states he sleeps well at night with minimal interruption, wakes up 1-2x a night to urinate. States drinks a glass of water prior to going to bed. Reports his appetite is good, eats 2-3 meals per day, mainly prepared by daughter. As per daughter, patient is not able to cook for himself. Typical diet is as follows:

• Breakfast: 1 cup of black coffee with no sugar; oatmeal or eggs with white toast
• Lunch: Sandwich w/ deli meat, lettuce and tomato or soup
• Dinner: Rice and beans, mixed vegetables, protein (typically chicken or fish)
• Patient states he snacks on bread and cookies throughout the day. Reports he eats fruits 4-5 x per week including apples, mangoes, oranges.
• As per daughter patient does not eat out often.
• Daughter admits that patient has a very carbohydrate heavy diet.

As per daughter, she has not noticed and mood changes in patient since his move to NYC. She states her father has a good memory and is able to recall things well, but sometimes does repeat himself, which has remained unchanged for years. Patient believes he is in good health and that his memory and understanding is good. Daughter states he is able to socialize well with family.

During today’s visit patient is currently complaining of productive cough x 1 month. Endorses sputum that is clear majority of the time, but sometimes yellow. Patient admits that cough is worse at night after he lays in bed. Patient states he has not tried any OTC products but sometimes eats a cough drop which has not helped his symptoms. Patient states cough has begun to improve over the past few days. As per daughter, patient’s great granddaughter whom he lives with had a sore throat and cough a few days prior to patient’s onset of the cough. Denies fever, chills, body aches, hemoptysis, night sweats, chest pain, weight loss, anorexia, SOB, nasal congestion, sore throat. Patient is unsure if he received BCG vaccine as a child.

As per patient, he has had mild difficulty with hearing from his right ear x 1 year. Patient states he does not have difficulty with speaking and hearing on the telephone. Reports if he does have the trouble with hearing it is usually due to distance. As per daughter, she sometimes needs to repeat herself if she is very far away from her father. States he cleans his ears with rag in shower, denies q-tip use. Denies ear pain, bleeding, discharge, tinnitus, dizziness.

Patient admits to urinary frequency x 1 month. States the frequency is occasional in nature and attributes this to drinking more water due to warmer temperature. Patient states he was never given medications for BPH in Mexico. Denies dysuria, urinary urgency, incontinence, hesitancy, dribbling.

As per patient he has been compliant with taking his metformin twice a day. Patient is independent in taking his medications. Patient does not have records of vaccinations but states that he does not recall receiving any vaccines other than COVID vaccine in past 20 years. Admits to 3 doses of COVID vaccine.

 

Cough differential diagnosis:

• Acute bronchitis/viral pathogen
• Pneumonia
• Tuberculosis
• COPD
• Interstitial lung disease (Hypersensitivity pneumonitis – Farmer’s lung)

 

Geriatric Assessment

• ADLs: Independent in all
• IADLs: Needs assistance in paying bills, shopping, transportation, meal preparation, household chores.
• Home Health Aide: None
• Visual impairment: None
• Hearing impairment: Yes (patient reports mild hearing loss of right ear) – pending audiology
• Falls in the past year: None
• Assistive devices used: None
• Gait impairment: None
• Urinary incontinence: None
• Fecal incontinence: None
• Osteoporosis: None
• Cognitive Impairment: None – Mini-cog: 3/5
  • Immediate word recall 3/3
  • Delayed word recall 3/3;
  • Clock 0/2 – unable to draw clock due to lack of education (highest level of schooling 1^st grade in Mexico)
  • Daughter reports no changes in memory or behavior at home
• Depression: None – PHQ 9 completed, score 0/27
• Home safety issues: None
  • Lives with daughter in apartment building on 5^th floor (building has elevator), when daughter is working (9-5 M-F) typically one of patient’s grandchildren are present at home
  • Daughter states house is free of clutter and carpets; reports grab bars in shower
• Health Care Proxy: Yes – D. M. (daughter) xxx-xxx-xxxx
• Advance Directives: Full code

 

Past Medical History

Medical History:

• BPH s/p TURP in 2016 (2015 – present)
• Type II Diabetes Mellitus (2019 – present)
• No past hospitalizations or history of blood transfusions.

Medications:

• Metformin 850mg PO BID for diabetes
• Denies current OTC medication use.
• Denies herbal supplement use.

Surgical History:

• Transurethral resection of prostate (TURP) in 2016 – performed in Mexico; no reported complications

Immunization History:

• No vaccination records available.
• Patient has 3 doses of COVID vaccine.

Allergies:

• No known drug/food/environmental allergies

Family History:

• Mother: Deceased age 92 from unknown cause. Hx T2DM
• Father: unknown
• Patient has 6 children ranging from age 39 – 60, alive and well
• No known family hx of cancer or heart disease

Social History:

• Smoking: Former (quit date: 05/12/2003), 5 pack years hx
• Alcohol: Denies current alcohol use, reports previously would drink 2-3 beers/week, reports last drink around 2015
• Denies past or current illicit drug use
• Marital History: Widowed, wife deceased 5 years ago (2018) from breast cancer
• Language: Patient requires Spanish translation. Unable to read or write.
• Education: Minimal education reported, reports completed until 1^st grade in Mexico
• Occupational History: Farm worker (cutting crops) for about 65 years in Mexico
• Travel: From Mexico 1 month ago (May 2023)
• Home situation: Lives in 3 bedroom apartment on 5^th floor (building has elevator but patient sometimes takes stairs), patient states he feels safe at home. Patient lives with daughter, 1 grandchild and great granddaughter. Patient has his own room with window that lets in sunlight.
• Sleep: States he sleeps well about 7-8 hours per night, reports he wakes up about 1-2x per night to urinate
• Exercise: Patient states he walks daily at least 10 blocks with granddaughter
• Diet: Daughter states she does the cooking – 2-3 meals per day, carbohydrate heavy (rice, pasta, bread), small piece of protein or fish and vegetables
• Caffeine: Patient reports 1 cup of black coffee in morning, no sugar
• Sexual history: Heterosexual – not currently sexually active; No history of known STIs

 

ROS:

• General: Denies fatigue, fever, chills, night sweats, weight loss/gain, changes in appetite.
• Skin, hair, nails: Denies discolorations, moles, rashes, changes in hair distribution or texture, pruritus.
• HEENT: Admits to decreased hearing of right ear. Denies head trauma, vertigo, visual disturbances, ear pain, tinnitus, epistaxis, discharge, congestion, sore throat bleeding gums. Patient states last dental visit was about 2 years ago. Last eye visit about 1 year ago.
• Neck: Denies localized swelling/lumps, stiffness/decreased ROM
• Pulmonary: Admits to cough. Denies dyspnea, wheezing, cyanosis, hemoptysis.
• Cardiovascular: Denies chest pain, edema/swelling of ankles or feet, palpitations.
• Gastrointestinal: Denies abdominal pain, nausea, vomiting, diarrhea, constipation, intolerance to specific foods, dysphagia, rectal bleeding, melena. Last colonoscopy 10-15 years ago, normal.
• Genitourinary: Admits to occasional frequency. Denies urgency, incontinence, hesitancy, dribbling.
• Musculoskeletal: Denies muscle pain, joint pain, arthritis, or swelling.
• Nervous system: Denies headache, loss of strength, change in cognition/mental status/memory.
• Peripheral vascular: Denies intermittent claudication, varicose veins, coldness of extremities, color changes, peripheral edema.
• Hematologic: Denies anemia, easy bruising or bleeding, lymph node enlargement, history of DVT/PE.
• Endocrine: Denies polydipsia, polyphagia, heat or cold intolerance, excessive sweating.
• Psychiatric: Denies depression/sadness or anxiety.

 

Physical Exam:

Vitals:

• Weight: 152.8 lbs Height: 62 inches       BMI: 28.82 kg/m²
• BP: 129/72, right arm sitting
• RR: 18, unlabored
• HR: 84, regular
• Temp: 98.2 F oral
• SpO2: 97% room air

General: 79-year-old male who appears stated age. Well-groomed and good posture. A/O x 3 and appears in no acute distress.

Skin: Warm, moist & intact. No rashes, cyanosis, moles, or lesions noted.

Head: Normocephalic & atraumatic

Eyes: Symmetrical OU. Sclera white, cornea and lens clear and conjunctiva pink. PERRL. EOM intact with no nystagmus.

Ears: Ears symmetric and appropriate in size. No lesions or masses on external ear. Mild amount of cerumen noted in RT ear, not impacted. TM clearly visualized, pearly grey & in good position AU. Auditory acuity intact to whispered voice AU.

Nose: Symmetrical. No rhinorrhea noted. Nares patent B/L.

Mouth/Throat: Mucus membranes moist. Good dentition, no dental caries noted. Pharynx non-erythematous. No exudates present.

Neck: Trachea midline. Neck supple and non-tender. No lymphadenopathy present. Carotid pulses 2+. No carotid bruit auscultated. FROM without pain and strong shoulder shrug.

Thyroid: Non-tender to palpation, no thyromegaly noted, no palpable nodules or masses.

Heart: Regular rate and rhythm. S1 & S2 distinct with no murmurs or gallops.

Chest: Symmetrical, no deformities. Non-tender to palpation. Chest expansion symmetrical with no accessory muscle use.

Lungs: Clear to auscultation B/L. No adventitious sounds noted. Clear to percussion B/L. Tactile fremitus symmetric throughout.

Abdominal: Abdomen symmetric and non-distended, with no striae or scars. Normoactive bowel sounds in all 4 quadrants. Non-tender to palpation and tympanic throughout with no guarding or rebound No abdominal hernias noted. No CVA tenderness appreciated.

Neurologic:

• Mental status: Patient alert and oriented to person, place and time. No tics or tremors.
• Motor/cerebellar: Gait steady, no ataxia or impairment noted. Romberg negative, no pronator drift noted. Get up and go test < 10 seconds. Patient able to follow three—step commands.
• Mini-Cog: 3/5 (3/3 word recall and 0/2 clock – unable to perform clock due to limited schooling)
• Mood: No depression, anxiety or suicidal ideations.
• Sensory: intact to light and sharp/dull sensations bilaterally.
• Reflexes: Bicep and patellar reflexes intact and 2+ bilaterally.
• No cranial nerve deficit observed.

Musculoskeletal: No soft tissue swelling, erythema, ecchymosis or deformities. No muscular atrophy noted in upper or lower extremities. Bilateral upper and lower extremities 5/5 in strength.

• Neck/Spine: No muscular atrophy noted. No evidence of spinal deformities or scoliosis. No pain to palpation of spinous processes or paravertebral muscles. Neck flexion, extension, rotation and lateral flexion intact without pain. Spinal flexion and extension intact without pain.
• Shoulders: No atrophy noted. Flexion/extension, external/internal rotation and abduction/adduction intact without pain.
• Arm/Elbow: No atrophy noted. Flexion/extension & supination/pronation intact without pain.
• Hand/wrist: Symmetrical, no swelling, erythema or boney changes noted. No Heberden’s or Bouchard’s nodes present. Flexion and extension of wrist and hand intact without pain.
• Hips: No muscular atrophy noted. Flexion/extension, external/internal rotation and abduction/adduction intact without pain.
• Knee: No soft tissue swelling or atrophy of quadricep muscle. Flexion/extension, external/internal rotation intact without pain.
• Feet/ankles: No soft tissue swelling or atrophy noted. Inversion/eversion & dorsiflexion/plantar flexion intact without pain.

Peripheral vascular: Extremities are symmetrical and normal in size, color and temperature. No edema or stasis changes noted. Pulses 2+ bilaterally in upper and lower extremities. No calf tenderness.

Foot exam: Skin in warm and intact. No edema, erythema, lesions or ulcers notes. Right great toe nail thickened & yellow. Nails appropriate in length. 2+ dorsalis pedis and posterior tibial pulses bilaterally.

 

Labs:

CBC	Reference Range	5/18/23
WBC	3.80 – 10.50 K/uL	7.07
RBC	4.20 – 5.80 K/uL	4.98
HGB	13.0 – 17.0 g/dL	14.5
HCT	39.0 – 50.0%	44.2
MCV	80.0 – 100.0 fl	88.8
MCH	27.0 – 34.0 pg	29.1
MCHC	32.0 – 36.0 gm/dL	32.8
RDW	10.3 – 14.5 %	14.4
PLT	150 – 400 K/uL	184
Neutrophil %	43.0 – 77.0%	52.2

 

CMP	Reference Range	5/18/23
Sodium	135-145 mmol/L	140
Potassium	3.5 – 5.3 mmol/L	4.5
Chloride	96 – 108 mmol/L	102
CO2	22- 31 mmol/L	22
BUN	7-23 mg/dL	22
Creatinine	0.50 – 1.30 mg/dL	0.95
Glucose	70 – 99 mg/dL	185
Calcium	8.4 – 10.5 mg/dL	9.0
Albumin	3.3 – 5.0 g/dL	4.0
Total protein	6.0 – 8.3 g/dL	6.8
Total bilirubin	0.2 – 1.2 mg/dL	0.4
ALK Phos	40 – 120 U/L	115
ALT	10 – 45 U/L	3618
AST	10 – 40 U/L	27
eGFR	> = 60 ml/min/1.73m2	81

 

	Reference Range	5/18/23
Hemoglobin A1C	4.0 – 5.6%	8.9
TSH	0.27 – 4.20 uIU/mL	1.70
Microalbumin/Creatinine Urine	0 – 30 mg/g	14
PSA	0.00 – 4.00 ng/mL	2.04
Fecal Occult Blood Immuno	Negative	Negative

 

Urinalysis	Reference Range	5/18/23
pH Urine	5.0 – 8.0	6.5
Color urine	Yellow	Yellow
Apperance Urine	Clear	Clear
Glucose Qualitative Urine	Negative mg/dL	Negative
Bilirubin Urine	Negative	Negative
Ketones Urine	Negative mg/dL	Negative
Specific Gravity	1.005 – 1.030	1.012
Blood Urine	Negative	Negative
Protein Urine	Negative mg/dL	Negative
Urobilinogen Urine	0.2 – 1.0 mg/dL	0.2
Nitrite Urine	Negative	Negative
Leukocyte Esterase Urine	Negative	Negative
White Blood Cells Urine	0 – 5 /HPF	1
Red Blood Cells Urine	0 – 4 /HPF	0
Bacteria Urine	Negative /HPF	Negative
Cast Urine	0 – 4 /LPF	0
Urine Epithelial Cells	0 – 5 /HPF	1

 

Lipid Panel	Reference Range	5/18/23
Cholesterol	< = 199 mg/dL	181
HDL Cholesterol	> = 41 mg/dL	47
Triglyceride	< = 149 mg/dL	109
LDL Cholesterol	< = 99 mg/dL	112
Non-HDL Cholesterol	< = 129 mg/dL	134

 

Assessment/Plan:

#Type 2 DM – Not adequately controlled

• Metformin dosage adjusted to 1000mg tablet BID
• Started on empagliflozin (Jardiance) 10 mg tablet PO QD
• Encouraged ADA diet & exercise as tolerated
• Repeat A1C in 3 months

#Cough – productive x 1 month

• CXR
• Quantiferon
• Guaifenesin (robitussin) 100mg/5mL PO TID PRN
• Benzonatate (tessalon) 100 mg capsule PO TID x 7 days
• Patient advised to call office & return if symptoms worsen, if notices blood in sputum, or if develops fevers/chills/body aches

#Onychomycosis of right great toe

• Started on ciclopirox (loprox) 0.77% cream BID on affected nail & advised to use for 9 months
• Encouraged use of cotton socks and to change socks daily
• Podiatry pending & scheduled for 07/07/23

#Hyperlipidemia

• LDL elevated to 112 on 5/18
• Advised heart healthy diet and exercise
• Will reassess lipid panel in 3 months

#BPH s/p TURP

• Patient reports occasional frequency, not currently on any therapy
• PSA currently within normal limits
• Urology referral given & scheduled for 06/29/23

#Hearing loss of right ear x 1 year (patient classifies as mild)

• Whisper test negative on affected side
• Audiology referral given & scheduled for 08/09/23

#Health maintenance

• TDAP given today 6/6
• Prevnar 20 vaccine given today 6/6
• STI screening completed today
• Multi vitamin prescribed 1 tablet PO QD
• Dental referral given today & pending
• Ophthalmology referral given & scheduled for 08/09/23
• Patient offered colonoscopy and declines
• Vaccinations to give next visit:
  • Pneumovax 23
  • Shingrix dose #1

RTC: in 3 months, please complete bloodwork (fasting) 1 week prior to visit

/s/ Nia Grant, PA-S