CC: "I feel very weak lately"
Mrs. Humphrey is a 92 year old who presents to your clinic with her daughter who is also her caregiver. She was recently on Levofloxacin for a UTI about one week ago. She does not have any urinary symptoms but is concerned because she is very weak and does not have the strength to walk far distances without resting. She also states that she is feeling more "foggy" lately and is having difficulty concentrating for example she is unable to balance her checkbook and is something she has been able to do without difficulty. She is a little more short of breath than usual and has increased edema in both feet worse at the end of the day. She reports occasional diarrhea the last week.
She was recently started on Amlodipine 5mg daily because her blood pressure was a little elevated about a month ago. Other than that, all of her medications are the same.
ROS:
General: Denies weight loss/gain, no fever, chills or night sweats, see HPI
HEENT: No recent cold sx, otherwise negative
Resp: No cough or wheezing, see HPI
CV: Denies CP, palpitations, orthopnea or PND
Abdomen: Denies abdominal pain, appetite is fair, see HPI
Ext: No claudication, calf pain or venous insufficiency, see HPI
Neuro: No parestheisas, no numbness or tingling
PMH:HTN, Afib, Osteoporosis, PUD, OAB
PSH: None
Allergies: None
Social: Never smoked or drank
Meds:
Coumadin 5mg daily
Amlodipine 5mg daily
Metoprolol 50mg bid
Oxybutinin 5mg daily
Calcium 600mg bid
Aspirin 81mg daily
Ranitidine 150mg bid
Omeprazole 20mg daily
Physical Exam:
VS: BP sitting 110/66 P- 100; Lying 120/84 P- 98, standing 90/48 P- 110, RR 22 HT: 5'6" Wt: 175 BMI = ........Pulse ox: 93% RA
Lungs: Bilateral rales to lower lobes, no wheeze
Heart: Irregular- good S1 and S2. No S3 or S4, murmurs, rubs, or gallops.
Abdomen: + BS x 4 quadrants. No masses or tenderness. No hepatomegaly. No CVAT, no suprapubic tenderness
Ext: +2 PPP bilateral DP and PT, +1-2 pitting edema to bilateral lower ext
Neuro: A&Ox3, 28/30 MMSE (down 2 points from last visit, unable to draw intersecting pentagons and write a sentence), Clock drawing test-all points
# MMSE above 26 is still normal but pt dropped 2 points, dropped 3 points will be concerned. Pt started to have mild impairment as she has problem managing finances , monitor and assess for sign of abuse
Labs:
UA---Negative LE and nitrates
Trace Hgb
Trace protein
Stool for OB +
No recent labs, last drawn a year ago
Question 1: Name the top 3 differential diagnoses for this patient.
Question 2: What, if any of her medications would you consider discontinuing or adjusting?
Question 3: Which of the following labs/diagnostic tests would you consider ordering for this patient?
Question 4: Given her age and symptomatology, what is the most likely cause of her foggy?
Question 5: You have her follow up in 2 months. When administering the MMSE, you notice her score has remained the same at 24/30. What would your next course of action be?
Question 6: Which medications might you consider prescribing given her presentation?