Identifying Data

Full Name: S. Z.

Sex: Female

DOB: xx/xx/1939

Date & Time: June 16, 2023 11:00 pm

Location: Metropolitan Hospital Center

Religion: Unspecified

Source of Information: Self

Reliability: Reliable

Source of referral: Self

Mode of transportation: Bus

 

Chief Complaint: “Stomach pain” x 3 weeks

 

History of Present Illness:

S.Z. is an 84 y/o F independent in ADLs and IADLs ambulating freely to the geriatric clinic with PMHx of hypertension, hyperlipidemia, right carotid artery stenosis, type II diabetes, osteoporosis, and seizure disorder presenting for a follow up visit accompanied by husband. Patient was last seen in clinic on 2/14/2023 for follow up complaining of poor appetite due to a broken tooth (tooth #30). Patient opted to follow up with private dentist in Argentina and had tooth repaired with crown. Patient states her appetite has improved and has gained 2lbs since previous visit. At that time, labs were drawn and were within normal limits. Upon review of patient records, patient has missed multiple neurology follow up visits for seizure disorder, last visit with neurology was November 2021. Patient states she was unaware of appointments and has been off Keppra since that time. Patient denies breakthrough seizures and reports her last seizure was around March 2021.

Today patient complains of new onset epigastric abdominal pain x 3 weeks. Patient describes the pain as burning, moderate in intensity. Patient states pain worsens when lying down. Reports that pain has no relation to meals. Patient states the pain is intermittent and usually lasts about 3 days of the week and returns the next week. Pain does not radiate. Patient states she has used OTC tums which provides temporary relief. Patient states she has not had a recent change in diet and has not tried any new foods. Patient has been on alendronate therapy for about 1 year but states she stopped taking it prior to having her dental crown placed, states she resumed therapy about 2 months ago. Patient states she has been compliant and follows correct administration instructions by taking it with full glass of water and sitting up after administration. Patient states she does not drink alcohol. Denies nausea, vomiting, constipation, diarrhea, hematemesis, melena, hematochezia, heart burn, chest pain, weight loss, bloating, dysphagia, odynophagia, loss of appetite, sore throat, fever. Last BM this morning, normal consistency.

 

Abdominal pain differential diagnosis:

Pill Esophagitis

GERD

Gastritis

PUD

Upper GI bleed

Pancreatitis

Gastric/esophageal adenocarcinoma

 

Geriatric Assessment

• ADLs: Independent in all
• IADLs: Independent in all
• Home Health Aide: None
• Visual impairment: Yes – patient wears glasses; to follow with ophthalmology
• Hearing impairment: None
• Falls in the past year: None
• Assistive devices used: None
• Gait impairment: None
• Urinary incontinence: None
• Fecal incontinence: None
• Osteoporosis: Yes – Dexa scan 2022: lumbar T score -4.2; dual femur T score -2.1
• Cognitive Impairment: None – Mini-cog: 5/5
• Depression: None – PHQ 9 completed, score 0/27
• Home safety issues: None
• Health Care Proxy: Yes – Husband M. Z. (xxx-xxx-xxxx)
• Advance Directives: Full code

 

Past Medical History

Medical History:

• Hypertension (2019 – present)
• Carotid artery stenosis (2021 – present)
• Hyperlipidemia (2019 – present)
• Type II Diabetes Mellitus (2015 – present)
• Osteoporosis (2022 – present)
• Seizure disorder (2019 – 2021)
• No past hospitalizations or history of blood transfusions.

Medications:

• Alendronate (Fosamax) 70 mg 1 tablet PO every 7 days; for osteoporosis
• Atorvastatin (Lipitor) 50 mg 1 tablet PO QD; for hyperlipidemia
• Calcium-carbonate-vit-D mineral 600-400 mg unit chew 1 tablet BID; for osteoporosis
• Clopidogrel (Plavix) 75mg 1 tablet PO QD; for CAD
• Lisinopril (zestril) 5 mg tablet PO QD; for hypertension
• Multi-vitamin (centrum silver 50+ women) 1 tablet PO QD
• Denies current OTC medication use.
• Denies herbal supplement use.

Surgical History:

• Procedures:
  • Electroencephalography (EEG) 03/30/21 at metropolitan hospital, no complications

Immunization History:

• Pfizer SARS-COV2-Vaccine: 5/24/21, 6/14/21, 2/18/22
• Bivalent Pfizer SARS-COV2-Vaccine: 1/18/23
• Pneumovax 23: 11/1/21
• Influenza: 11/1/2022
• TDAP: 10/19/21

Allergies:

• No known drug/food/environmental allergies

Family History:

• Mother: Deceased age 97 from natural causes. No known medical hx.
• Father: Deceased age 86 from MI. Hx HTN, HLD, DM II.
• 2 children: Alive and well, living in NY.

Social History:

• Smoking: Never
• Alcohol: Never
• Denies past or current illicit drug use
• Marital History: Married to husband for 50 years.
• Language: Patient requires Spanish translation, able to read and write
• Education: High school graduate
• Occupational History: Retired, previously a seamstress
• Travel: Argentina, returned about 2 months ago
• Home situation: Patient has 2 residences – 1 in NY and 1 in Argentina. Patient predominantly lives in NY with husband to be close to her children and grandchildren. Lives in an apartment building in Queens, NY. 3^rd floor apartment with elevator in building, patient states she prefers to take the stairs.
• Sleep: Patient states she sleeps well about 8 hours per day. Sleeps at 10pm and wakes at 6 am.
• Exercise: Patient can walk about 15 blocks without stopping and with no chest pain or SOB. Reports daily walks in central park when the weather is nice with husband for exercise.
• Diet:
  • Breakfast: oatmeal with coffee
  • Lunch: pasta or sandwich
  • Dinner: salad, brown rice & beans, roasted chicken
• Caffeine: 1 cup of coffee daily with milk and sugar.
• Sexual history: Not currently sexually active. No known history of STIs.

 

ROS:

• General: Denies fatigue, fever, chills, night sweats, weight loss, changes in appetite.
• Skin, hair, nails: Denies discolorations, moles, rashes, changes in hair distribution or texture, pruritus.
• HEENT: Denies head trauma, vertigo, visual disturbances, ear pain, hearing loss, tinnitus, epistaxis, discharge, congestion, sore throat, bleeding gums. Patient states last dental visit was about 3 months ago. Last ophthalmology visit 1 year ago.
• Neck: Denies localized swelling/lumps, stiffness/decreased ROM
• Breast: Last mammogram 8/17/2017 nml, pt declines mammogram screening. Denies pain, swelling, discharge.
• Pulmonary: Denies cough, dyspnea, wheezing, cyanosis, hemoptysis.
• Cardiovascular: Denies chest pain, edema/swelling of ankles or feet, palpitations.
• Gastrointestinal: See HPI. Last colonoscopy 2017, nml, pt declines updated screening.
• Genitourinary: Denies urgency, frequency, incontinence, hesitancy, dribbling.
• Musculoskeletal: Denies muscle pain, joint pain, arthritis, or swelling.
• Nervous system: Admits to history of seizures. 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 or anxiety.

 

Physical Exam:

Vitals:

• Weight: 94 lb Height: 57 inches       BMI: 20.51 kg/m²
• BP: 134/85, left arm sitting
• RR: 18, unlabored
• HR: 83, regular
• Temp: 98.2 F oral
• SpO2: 98% room air

General: 84-year-old slender female who appears stated age. Well-groomed and good posture. A/O x 3 and appears in no acute distress.

Skin: Warm, dry & 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. 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. Pharynx non-erythematous. No exudates present.

Neck: Trachea midline. Neck supple and non-tender. No lymphadenopathy present. Carotid pulses 2+. Right sided carotid artery bruit auscultated. FROM without pain.

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.

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. Negative murphy’s sign.

Neurologic:

• Mental status: alert and oriented to person, place and time.
• Mood: No depression, anxiety or suicidal ideations.
• Cranial Nerves:
  • CN II: visual fields intact to finger counting
  • CN III, IV, VI: PERRL, extraocular muscles intact with full range of movement
  • CN V: normal facial sensation, muscles of mastication are normal and symmetric
  • CN VII: facial musculature is symmetric and expressions intact
  • CN VIII: hearing is intact bilaterally to whisper test
  • CN IX, X: normal palatal elevation, uvula is midline
  • CN XI: sternocleidomastoid muscles are 5/5 bilaterally, trapezius muscles are 5/5 bilaterally
• Sensation:
  • Light and dull touch: normal, symmetric in bilateral upper and lower extremities
• Motor/cerebellar:
  • Gait steady, no ataxia or impairment noted.
  • Romberg negative, no pronator drift noted.
  • Get up and go test: < 15 seconds
• Reflexes:
  • Bicep: Right 2+/4, Left 2+/4
  • Tricep: Right 2+/4, Left 2+/4
  • Brachioradialis: Right 2+/4, Left 2+/4
  • Patellar: Right 2+/4, Left 2+/4
  • Achilles: Right 2+/4, Left 2+/4
  • Plantar reflex: Babinski negative
• Mini-Cog: 5/5 (3/3 immediate recall, 3/3 delayed recall, 2/2 clock & time placement)

Musculoskeletal: No soft tissue swelling, erythema, ecchymosis or deformities.

• 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 5/5 in strength and abduction/adduction 5/5 strength. External/internal rotation intact without pain.
• Elbow: No atrophy noted. Flexion/extension 5/5 in strength. No cog-wheel rigidity noted with passive supination/pronation.
• Hand/wrist: Symmetrical, no swelling, erythema or boney changes noted. No Heberden’s or Bouchard’s nodes present. Flexion and extension of wrist and fingers intact without pain. Grip strength 5/5.
• 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 5/5 in strength. 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. Nails well-trimmed and appropriate in length. 2+ dorsalis pedis and posterior tibial pulses bilaterally.

 

Assessment/Plan:

#Abdominal pain

• Discontinue alendronate 70 mg effective immediately
• Labs today (CBC) to rule out bleed
• Patient advised that if epigastric pain continues 1 week after drug discontinuation to return for upper endoscopy scheduling

#Osteoporosis

• Dexa scan 2022: lumbar T score -4.2; dual femur T score -2.1
• Patient is currently on alendronate but reports epigastric abdominal pain.

Plan:

• Continue on Calcium & vitamin D
• Discontinue alendronate effective immediately
• Weightbearing exercises recommended
• Endo referral given for possible initiation of denosumab

#Type II DM – controlled

• Currently controlled on dietary modifications
• A1C 6.1

Plan:

• Continue dietary modifications
• Will continue A1C monitoring

#Hypertension – controlled

• BP today 134/85

Plan:

• Continue Lisinopril 5 mg

#CAD – right carotid artery stenosis

• Carotid duplex 04/15/2021 revealing right side 50% carotid artery stenosis and left side normal %
• Patient was unable to tolerate ASA due to GI upset so was started on Plavix

Plan:

• Continue on Plavix 75 mg

#Hyperlipidemia – controlled

Plan:

• Continue Lipitor 40 mg
• Continue heart healthy diet and exercise

#Seizure disorder

• Patient was last seen by neurology 11/2021; as per last neurology note patient should have continued Keppra 500 mg BID but patient has not been taking it for over 1 year
• Last seizure patient reports around March 2021

Plan:

• Patient educated about the importance of taking her medication
• Neurology follow up appointment given to determine whether to restart Keppra

#Health maintenance

• Shingrix dose #1 given today
• Prevnar 20 vaccine given today
• Dental referral given today
• Ophthalmology referral given today (scheduled 06/21/23)
• Last podiatry visit 3/2023
• Continue on multi-vitamin

RTC: in 4 months(10/20/23), please complete bloodwork (fasting) 1 week prior to visit (10/13/23)

/s/ Nia Grant, PA-S