History
CC:
Monthly comprehensive H&P
HPI:
This is an 87 year old male with an extensive PMHx who was seen and examined today for his monthly comprehensive exam. Pt was started on Tagrisso, an oral chemotherapeutic agent, by his oncologist for his diagnosed lung cancer in 06/2024 which caused him to rapidly decline. Pt refused to get out of bed, eat and his HR continuously dropped. During that time the family declined all other interventions and consults. Together with the family and the oncologist, the decision was made to discontinue the medication in 07/2024 and was put on palliative care. After that, the pt regained his energy almost immediately. Pt was seen out of bed today in his wheelchair in NAD. Pt was awake, alert and verbally responsive throughout the conversation. Pt was oriented to person and time, but remained confused about his location for the duration of the encounter. Pt has a hx of glaucoma complicated by legal blindness and endorsed eye pain and dryness which he says he experiences randomly throughout the day for a while. He mentioned that he also experiences dry mouth where his “tongue feels stuck.” He denies any pain in his mouth. When asked how he is feeling, he said he feels sad because a lot is going wrong for him and that he knows he “is going to die.”
Pt denied all other pain, cough, fever/chills, loss of appetite, change in bowel habits, nasal congestion, shortness of breath and suicidal ideation.
PMHx:
Present chronic illnesses-
- Lung cancer stage 3A
- CAD
- HTN
- HLD
- Glaucoma with legal blindness
- BPH
- A. Fib
- MDD
Past medical illnesses-
- TIA- 2010, 2015
Childhood illnesses-
- Denies
Immunizations-
- Up to date
Screening tests and results-
- Unknown
Past Surgical History-
- Unknown
Medications-
- Acetazolamide 250 mg, 1 tab BID for glaucoma
- Brinzolamide suspension 1%, 1 drop in both eyes TID for glaucoma
- Latanoprost solution 0.005%, 1 drop in both eyes QHS for glaucoma
- Brimonidine tartrate-Timolol maleate ophthalmic solution 0.2-0.5%, 1 drop in both eyes BID for glaucoma
- Polyethyl glycol-Propyl glycol solution 0.4-0.3%, 1 drop in both eyes four times/day for glaucoma
- Clopidogrel 75 mg, 1 tab QD for clot prevention
- Aspirin 81 mg, 1 tab QD for A. Fib
- Tamsulosin 0.4 mg, 1 capsule QHS for BPH
Allergies-
- No known drug, food or environmental allergies.
Family History:
- Unknown
Social History:
- S.C. is widowed. He is a full-time resident at the Gouverneur SNF. He has one step-daughter and two daughters that are involved in his care.
- Pt is dependent in all ADLs. He is wheelchair bound and requires a 1 person assist with all ADLs (dressing, bathing, transferring, eating etc.)
- Pt is continent of urine and stool.
- Pt is a retired construction worker.
- Pt denies alcohol intake.
- Pt denies current cigarette use, but has a 50 pack year history (quit 10 years ago).
- Pt denies drinking coffee.
- Pt denies illicit drug use.
- Pt denies recent travel.
- Pt says he eats the food provided to him at the SNF.
- Pt reports getting about 9-10 hours of sleep each night and feels rested.
- Pt is not sexually active.
Review of Systems:
- General: Denies fever, fatigue, chills, night sweats, weight loss/gain and loss of appetite.
- Skin, hair, nails: Denies discolorations, moles, rashes, changes in hair distribution or texture, pruritus.
- HEENT: Admits to dry eyes, dry mouth and eye pain. Denies head trauma, vertigo, visual disturbances, ear pain, hearing loss, tinnitus, epistaxis, discharge, congestion, sore throat, bleeding gums.
- Neck: Denies localized swelling/lumps, stiffness/decreased ROM
- Pulmonary: Denies cough, dyspnea, wheezing, cyanosis, hemoptysis.
- Cardiovascular: Denies chest pain, edema/swelling of ankles or feet, palpitations.
- Gastrointestinal: Denies abdominal pain, nausea, vomiting, jaundice, diarrhea, constipation, dysphagia, pyrosis, flatulence, eructation, rectal bleeding, hemorrhoids or blood in stool.
- Genitourinary: Denies urinary frequency, nocturia, urgency, flank pain, oliguria, polyuria and incontinence, dysuria and malodorous urine.
- Musculoskeletal: Denies joint pain, arthritis, joint swelling, back pain and muscle pain.
- Nervous system: Denies seizures, headache, loss of consciousness, sensory disturbances, ataxia, loss of strength, change in cognition/mental status/memory.
- Peripheral vascular: Denies intermittent claudication, coldness or trophic changes, varicose veins, peripheral edema, or color changes.
- Hematologic: Denies anemia, easy bruising or bleeding, lymph node enlargement, history of DVT/PE.
- Endocrine: Denies polyuria, polydipsia, polyphagia, heat or cold intolerance, goiter, excessive sweating, or hirsutism.
- Psychiatric: Admits to feelings of sadness. Denies feelings of helplessness, hopelessness, lack of interest in usual activities, or suicidal ideations, anxiety, obsessive/compulsive disorder.
Physical
General:
- Well developed, well nourished male in NAD. Appears stated age of 87. Neatly groomed, alert and oriented x2 (person and time).
Vitals:
- BP: 116/74 mm Hg
- R: 18/min, regular rate and rhythm, unlabored
- P: 66 beats per minute, regular rate, rhythm and amplitude
- SpO2: 95% on room air
- T: 98 degrees F (temporal)
- Height: 69 inches Weight: 144 lbs BMI: 21.3
Skin & Head:
- Skin: Warm and moist, good turgor. Nonicteric, no lesions, scars, or tattoos noted.
- Hair: Bald with no excoriations.
- Nails: No clubbing, cyanosis, or lesions. Capillary refill < 2 seconds in upper and lower extremities.
- Head: Normocephalic, atraumatic with no evidence of contusions, ecchymoses, hematomas, or lacerations, and nontender to palpation throughout.
- Eyes: Symmetrical OU. EOMS intact, no strabismus, nystagmus, exophthalmos, or ptosis. White ring around b/l irises. Pupils not reactive to light b/l.
Nose/Sinuses:
- Nose: Symmetrical. No masses, lesions, deformities, trauma. No discharge visualized. Nares patent bilaterally. Nasal mucosa is pink and well hydrated. Septum midline without lesions, deformities, injection, or perforation. No foreign bodies.
Mouth/Pharynx:
- Teeth: Multiple missing teeth.
- Tongue: Pink and well papillated. No masses, lesions or deviation. No fasciculations.
- Oropharynx: Well hydrated. No injection, exudate, masses, lesions or foreign bodies. Tonsils present with no swelling, injection or exudate. Uvula midline, pink with no edema or lesions.
Thorax and Lungs:
- Chest: Pectus carinatum. Respirations unlabored/ no paradoxical respirations or use of accessory muscles noted. Non-tender to palpation throughout.
- Lungs: Clear to auscultation and percussion bilaterally. No adventitious sounds.
Cardiac Exam:
- Heart: Regular rate and rhythm. S1 and S2 are distinct with no murmurs, S3 or S4. No splitting of S2 or friction rubs appreciated.
Abdominal Exam:
- Abdomen with flat contour with no scars, striae or pulsations noted. Bowel sounds normoactive in all 4 quadrants with no aortic/renal/iliac or femoral bruits. Non-tender to palpation, soft and nondistended. No guarding or rebound noted.
Peripheral Vascular System:
- Extremities are warm and without edema. No varicosities or stasis changes. Calves are supple, equal in size, non erythematous and nontender. Pulses are 2+ and symmetric.
Musculoskeletal:
- Bilateral arms: No erythema, warmth or crepitus noted. Non-tender to palpation. Full range of motion.
- Back and lower extremities: Not assessed due to wheelchair bound.
Differential Diagnosis:
- Eye pain secondary to glaucoma
- Arcus senilis
- Poor oral hygiene
Assessment:
- This is an 87 year old male with an extensive PMHx who was seen and examined today for his monthly comprehensive exam. Pt has a PMHx which includes glaucoma complicated by legal blindness and has complaints of eye pain and dryness today. Pt also is experiencing dry mouth sometimes. Pt also admits to feelings of sadness. Otherwise, pt appears well with no urgent complaints. On exam, there is a noticeable white ring around the irises and the pupils are not ERRLA b/l. The oropharynx appears normal and moist with multiple missing teeth. Pt’s complaints are consistent with eye pain secondary to glaucoma and dry mouth due to poor oral hygiene and drinking. At this point there are no labs or imaging to review.
Plan:
- Palliative care
- Glaucoma/eye pain
- Continue medications as listed above
- Optho consult pending- family refused due to recent health complications, now they agreed to it
- Poor oral hygiene/dry mouth
- Increase oral hydration Q2H
- Assist with teeth brushing
- Saw dentist 10/17/24- return annually
- Hx of TIA/A. fib
- Continue clopidogrel and aspirin as listed above
- HLD/CAD/HTN
- BP controlled
- BPH
- Continue tamsulosin as listed above
- Hx of MDD, sad mood
- Psychology consult
- Lung cancer stage 3A
- Last oncology appointment 7/12/24
- D/c Tagrisso then
- Aspiration precaution
- RTC PRN
- Last oncology appointment 7/12/24
- Consults
- Dental- 10/17/24→ RTC annually
- Podiatry- 8/20/24→ RTC in 3 months
- Optho- pending
- Oncology- 7/12/24→ RTC PRN
- Cardio- 6/10/24→ RTC 12/9/24