felisalewis
New
REASON FOR CONSULTATION: 59-year-old with episode of syncope with history of palpitations, now with tachycardia, to evaluate from cardiac standpoint.
HISTORY OF PRESENT ILLNESS: Obtained from the chart. The patient is quite rambling historian. He appears to be awake, alert and oriented, conversant and articulate. However, his stories are extremely rambling and contradictory. He contradicts himself from symptoms to symptoms and becomes extremely confused, disoriented, and says that he was sorry and that he is just “all messed up”. On questions of orientation, he only knows his name. Time, place and person are completely inaccurate with the year 2020. He does not know the President. He does not know where we are and just cannot name the building we are in, and therefore, history per documents. He was admitted late last evening by Dr. with a history of facial droop, leg weakness and a possible stroke, but had a history of being seen at Lakewood Ranch apparently two weeks ago with severe diabetes mellitus, and congestive heart failure. We do not have records from that admission and the patient certainly cannot contribute to the history. He states that at one point he was window shopping at K-Mart and had a fall and “blacked out”, asked the manager to call the paramedics. He was taken to the nearest hospital and he does not know which hospital that was. I am not sure if he is going to confuse his Lakewood Ranch admission and this admission or not. At the present time, the patient denies any symptomatologies. He is walking about his room, dressed in a hospital gown and shorts and socks, straightening up his bed, moving all four extremities with ease and ambulating without any difficulties, moving all around the room.
ALLERGIES: He has no known drug allergies per chart.
MEDICATIONS: Per ER record.1. Metoprolol 25 mg daily. 2. Lisinopril 40 mg daily. 3. Crestor 10 mg daily. 4. Hydrochlorothiazide 25 mg daily. 5. Metformin 500 mg b.i.d. 6. Actos 15 daily. 7. Prednisone 10 mg daily. 8. Metoprolol 50 mg daily.
PAST MEDICAL HISTORY: As gleaned from the chart: 1. History of CHF with recent testing at Lakewood Hospital (?) including stress testing. He has had an echo at this facility. 2. Hypertension. 3. Diabetes mellitus. 4. History of dyslipidemia. 5. History of cholecystectomy.
SOCIAL HISTORY: He denies tobacco, alcohol or illicit drug use.
FAMILY HISTORY: The patient cannot contribute to this.
REVIEW OF SYSTEMS: Negative other than HPI and really cannot be obtained from the patient secondary to his confusion.
MEDICATIONS: At the time of consultation include: 1. Antifungal cream for scrotum.2. Cipro 500 mg b.i.d. p.o.3. Aspirin 81 mg daily.4. Metoprolol 25 mg b.i.d. 5. Lisinopril 20 mg daily. 6. Subcutaneous enoxaparin 40 mg for DVT prophylaxis. 7. Lantus insulin 10 units qHS.
PHYSICAL EXAMINATION:
GENERAL: Again shows an elderly gentleman “talking again and again”, but completely confused, except for his name without current symptomatic complaints, appears to be in no acute distress. VITAL SIGNS: Flow sheet examination shows respiratory rate of 18, saturation 92% on room air, temperature is 98.2 and heart rate is noted as 81, but was 111 with him walking around the room and sinus tachycardia by bedside monitor during my examination. Blood pressure currently is 150/89. At its peak today was 183/111 per review of CareVision's vital signs.
CHEST: Clear to auscultation, sitting. No rales or wheezes are present. HEART: Shows a regular rate and rhythm, rapid. Positive S3. No murmur or rub are heard.
EXTREMITIES: Show 1+ pretibial edema formation. Pedal pulses are not palpable.
ABDOMEN: Obese, soft and nontender. Normal bowel sounds are present. NECK: Supple. No carotid upstroke. No bruits are present.
HEAD: Atraumatic and normocephalic.
NEUROLOGIC: The patient moves all four extremities normally as noted and was ambulating in the room without any appearance of gait disturbance.
RESULTS OF LABORATORY EXAMINATION:
DIAGNOSTIC DATA: EKG shows sinus rhythm with PVC and early R-wave progression, nonspecific IVCD, left axis deviation consistent with left anterior hemiblock. Anterior Q-waves are noted, but quite small and nonspecific. Imaging services show a head CT on admission with atrophy and chronic small vessel ischemic changes. Chest x-ray shows no acute disease and has normal cardiac size and contour.
LABORATORY DATA: Troponins are less than 0.02, x3. Most recent troponin was 0.03, still within normal range. TSH normal at 0.635, glycated hemoglobin of 11.9 markedly elevated and multiple sugars have been markedly elevated as well. Most recent glucose is 201. Sodium of 141, potassium 3.9, chloride 103, CO2 29, BUN 20, creatinine 1.1 and calcium 9.1. Magnesium has not been assessed. Hematology examination shows white count 10,400, H&H 15.4 and hematocrit 5.0 and platelet count 241,000. The D-dimeris 0.37 with normal range less than 0.5.
ASSESSMENT: 1. Appearance of possible early dementia versus multi-infarct dementia with small vessel disease. Unable to get specific history. We will be very interested and we have asked nursing staff in HUC to please obtain the records in the morning from Lakewood Ranch to see what cardiac evaluation he has had. He did have an echo in our facility, which shows a significant anteroapical aneurysmal dilatation consistent with LAD from a previous infarction with probable underlying significant CAD. Most likely he will need cardiac catheterization for full evaluation and probably EP study with possible syncopal episode and significant diminution of left ventricular function as noted. 2. Neurologic evaluation for dementia of unknown etiology versus cerebrovascular accident. 3. Severe uncontrolled diabetes mellitus. Treatment per hospitalist service. 4. Severe hypertension. Would increase Lisinopril to 20 mg each day and Metoprolol to 50 mg p.o. b.i.d., especially with the tachycardia as noted. Further recommendations are pending. Review of old records from Lakewood Ranch evaluation and neurologic evaluation. We will follow.
HISTORY OF PRESENT ILLNESS: Obtained from the chart. The patient is quite rambling historian. He appears to be awake, alert and oriented, conversant and articulate. However, his stories are extremely rambling and contradictory. He contradicts himself from symptoms to symptoms and becomes extremely confused, disoriented, and says that he was sorry and that he is just “all messed up”. On questions of orientation, he only knows his name. Time, place and person are completely inaccurate with the year 2020. He does not know the President. He does not know where we are and just cannot name the building we are in, and therefore, history per documents. He was admitted late last evening by Dr. with a history of facial droop, leg weakness and a possible stroke, but had a history of being seen at Lakewood Ranch apparently two weeks ago with severe diabetes mellitus, and congestive heart failure. We do not have records from that admission and the patient certainly cannot contribute to the history. He states that at one point he was window shopping at K-Mart and had a fall and “blacked out”, asked the manager to call the paramedics. He was taken to the nearest hospital and he does not know which hospital that was. I am not sure if he is going to confuse his Lakewood Ranch admission and this admission or not. At the present time, the patient denies any symptomatologies. He is walking about his room, dressed in a hospital gown and shorts and socks, straightening up his bed, moving all four extremities with ease and ambulating without any difficulties, moving all around the room.
ALLERGIES: He has no known drug allergies per chart.
MEDICATIONS: Per ER record.1. Metoprolol 25 mg daily. 2. Lisinopril 40 mg daily. 3. Crestor 10 mg daily. 4. Hydrochlorothiazide 25 mg daily. 5. Metformin 500 mg b.i.d. 6. Actos 15 daily. 7. Prednisone 10 mg daily. 8. Metoprolol 50 mg daily.
PAST MEDICAL HISTORY: As gleaned from the chart: 1. History of CHF with recent testing at Lakewood Hospital (?) including stress testing. He has had an echo at this facility. 2. Hypertension. 3. Diabetes mellitus. 4. History of dyslipidemia. 5. History of cholecystectomy.
SOCIAL HISTORY: He denies tobacco, alcohol or illicit drug use.
FAMILY HISTORY: The patient cannot contribute to this.
REVIEW OF SYSTEMS: Negative other than HPI and really cannot be obtained from the patient secondary to his confusion.
MEDICATIONS: At the time of consultation include: 1. Antifungal cream for scrotum.2. Cipro 500 mg b.i.d. p.o.3. Aspirin 81 mg daily.4. Metoprolol 25 mg b.i.d. 5. Lisinopril 20 mg daily. 6. Subcutaneous enoxaparin 40 mg for DVT prophylaxis. 7. Lantus insulin 10 units qHS.
PHYSICAL EXAMINATION:
GENERAL: Again shows an elderly gentleman “talking again and again”, but completely confused, except for his name without current symptomatic complaints, appears to be in no acute distress. VITAL SIGNS: Flow sheet examination shows respiratory rate of 18, saturation 92% on room air, temperature is 98.2 and heart rate is noted as 81, but was 111 with him walking around the room and sinus tachycardia by bedside monitor during my examination. Blood pressure currently is 150/89. At its peak today was 183/111 per review of CareVision's vital signs.
CHEST: Clear to auscultation, sitting. No rales or wheezes are present. HEART: Shows a regular rate and rhythm, rapid. Positive S3. No murmur or rub are heard.
EXTREMITIES: Show 1+ pretibial edema formation. Pedal pulses are not palpable.
ABDOMEN: Obese, soft and nontender. Normal bowel sounds are present. NECK: Supple. No carotid upstroke. No bruits are present.
HEAD: Atraumatic and normocephalic.
NEUROLOGIC: The patient moves all four extremities normally as noted and was ambulating in the room without any appearance of gait disturbance.
RESULTS OF LABORATORY EXAMINATION:
DIAGNOSTIC DATA: EKG shows sinus rhythm with PVC and early R-wave progression, nonspecific IVCD, left axis deviation consistent with left anterior hemiblock. Anterior Q-waves are noted, but quite small and nonspecific. Imaging services show a head CT on admission with atrophy and chronic small vessel ischemic changes. Chest x-ray shows no acute disease and has normal cardiac size and contour.
LABORATORY DATA: Troponins are less than 0.02, x3. Most recent troponin was 0.03, still within normal range. TSH normal at 0.635, glycated hemoglobin of 11.9 markedly elevated and multiple sugars have been markedly elevated as well. Most recent glucose is 201. Sodium of 141, potassium 3.9, chloride 103, CO2 29, BUN 20, creatinine 1.1 and calcium 9.1. Magnesium has not been assessed. Hematology examination shows white count 10,400, H&H 15.4 and hematocrit 5.0 and platelet count 241,000. The D-dimeris 0.37 with normal range less than 0.5.
ASSESSMENT: 1. Appearance of possible early dementia versus multi-infarct dementia with small vessel disease. Unable to get specific history. We will be very interested and we have asked nursing staff in HUC to please obtain the records in the morning from Lakewood Ranch to see what cardiac evaluation he has had. He did have an echo in our facility, which shows a significant anteroapical aneurysmal dilatation consistent with LAD from a previous infarction with probable underlying significant CAD. Most likely he will need cardiac catheterization for full evaluation and probably EP study with possible syncopal episode and significant diminution of left ventricular function as noted. 2. Neurologic evaluation for dementia of unknown etiology versus cerebrovascular accident. 3. Severe uncontrolled diabetes mellitus. Treatment per hospitalist service. 4. Severe hypertension. Would increase Lisinopril to 20 mg each day and Metoprolol to 50 mg p.o. b.i.d., especially with the tachycardia as noted. Further recommendations are pending. Review of old records from Lakewood Ranch evaluation and neurologic evaluation. We will follow.