Case study on hypertesion and chest pains.

History of Present Illness:

Mr. AS, an 85 year old, Caucasian male, with a history of hypertension and chest pain presents today not knowing how he got to the assisted living facility. The patient states he arrived at the facility 3 years ago, unaware of how he got there or why (the chart states his arrival as April 28, 2009). Mr. AS states that he was told he had a stroke, and was aware that his legs were not working correctly. He doesn’t remember having the stroke, but states that he was 83 years old when it happened. He now has lost the ability to walk and has also given up trying. His legs and arms feel weak. His arms hurt from trying to use his walker. He currently does not lift weights to strengthen his arms so that they don’t get as exhausted when using his walker. Patient denies any prickling or tingling sensations. He also only exercises with his walker when he is made to, once a day during physical therapy. He states that he would rather use his wheelchair. He states that he has accepted the fact that he will not walk again, but is content just breathing and talking. He is not in any pain currently, still has feeling in his legs, but cannot move them. He also states that he was diagnosed with early stages of Alzheimers’ 30 years ago. His chart states that he was diagnosed with dementia at 55 years old. Patient is oriented to time and place, however, he has trouble remembering what he did yesterday. He can recall memories from years ago. He also states that he spends most of his day sleeping, but doesn’t feel tired, rather feels rested. Mr. AS also complains of coughing, that sometimes produces a clear sputum. He states that he was a smoker 20 years ago, for 40 years, with a 160 pack year history. He occasionally wheezes.

Past Medical History:

Current Medication List:

Mirtazapine 15 mg tablet PO once at bedtime for depression.

Namenda 10 mg tablet PO every 12 hours for Alzheimer’s.

Allopurinol 300 mg tablet PO 1 daily for hyperuricemia.

Aspirin single tablet chewable PO 81 mg to reduce the risk of heart attack and stroke, and pain relief.

Certavite antioxidant tablet 18 mg PO 1 daily as multivitamin and mineral supplement.

Loratadine 10 mg 1 tablet PO 1 daily for rhinorrhea/allergies.

Nifedipine 90 mg tablet PO 1 daily for chest pain and hypertension.

Metoprolol tartrate 25 mg PO 1 tablet daily for chest pain hypertension.

Nasal decongestant 0.05%SP 2 sprays per nostril 2 times a day for rhinorrhea/allergies.

Omeprazole 20 mg 1 table PO 2x a day for ulcers/ GERD.

Aricept 10 mg 1 tablet PO at bedtime for dementia.

Tamsulosin HCL 0.4mg capsule 1 PO at bedtime for benign prostatic hyperplasia.

Zolpidem tartrate 5 mg tablet 1 PO at bedtime as a sleep aid.

Acetaminophen 500 mg tablet give 2 tablespoon PO every 6 hours as needed for high temperatures.

Patient diagnosed with hypertension when he was 40 years old (currently controlled with medication). Patient states that he had a pace maker put in when he was 45 years old, and thinks it was to relieve chest pain. Patient thinks that he has been told he has high cholesterol, but he is unsure. Patients’ chart states that he has a history of hypertension, respiratory treatment, and chest pain. Patient was diagnosed with dementia at the age of 55, and had a stroke at 83 years old. Patient also had appendectomy due to appendicitis and an inguinal hernia repair when he was 10 years old. Patient has no known allergies.

Family History:

The patient states that he has one living adult son who calls often, but doesn’t visit much as he is overweight and has back pain. He remembers that one of his grandmothers’ passed away from TB, but he could not recall when. He has no grandchildren, and does not recall how anyone else in his family passed away. He states that he has no family history of hypertension, cancer, heart disease, diabetes mellitus, or psychiatric disease. He was married twice, and both wives are now deceased, but he does not remember when or the cause of death for either wife. No other information could be appreciated from the chart or patient, so a family member will need to be contacted to assess his risk for diseases.

Social History:

He currently has a girlfriend who lives in Miami Beach. The patient states that he currently is not sexually active, does not drink, do drugs, or smoke nicotine. He stopped smoking 20 years ago, but before that he smoked for 40-50 years, 4 packs a day (160 pack year history). Currently he does not follow a diet at the ALF, but eats what they feed him every day. He states that he builds clocks during the day as a hobby, and this keeps him happy.

Review of Systems:

General: Patient denies any fatigue, weight or appetite changes.

Skin: Patient denies any changes.

Head: Patient denies headaches, bumps/bruises, or dizziness.

Eyes: Patient states that he no longer needs to wear glasses since the stroke, as he can now see.

Ears: Patient can’t hear out of the left ear, but states that his right ear is fine.

Nose/Throat/Mouth: Patient denies any changes in smell or taste, or problems swallowing. He feels tickling in his throat when he talks too much.

Respiratory: Patient states that he has a constant cough, which sometimes produces clear sputum. He also occasionally wheezes and states that he had asthma as an adult and has used an inhaler.

Cardiovascular: Patient denies any pain, but states he has a pace maker. He denies palpitations as well.

Gastrointestinal: Patient denies any pain or cramping. Patient has been constipated for the past 20-30 years, only defecating once a month.

Genitourinary: He urinates 2-3 times a day, but has no control, and must wear a diaper. Patient denies polydipsia or hematuria.

Neurologic: See HPI

Musculoskeletal: See HPI

Endocrine: Patient denies any excessive thirst, changes in appetite, or weight changes.

Hematopoetic: Patient denies any skin color changes, easy bruising, or bleeding.

Psychiatric: SIGECAPS negative, and patient denies depression, fluctuating moods, or suicidal thoughts. See HPI

Physical Examination:

Vital Signs: Temp afebrile to touch, BP 132/72, pulse 60 bpm, RR 16 bpm, BMI 29

General: Overweight male currently not in respiratory or cardiac distress.

Skin: Darker brown discolored non-raised plaques on both arms, skin dry and warm to touch. Ulcers present on right ankle (2 cm wide, circular, and 1 cm above medial malleolus) and left shin (3 cm wide, circular, and 6 cm below tibial tuberosity). Left leg is erythematous, at the mid-tibia region.

HEENT: No icterus and no jaundice present, head is normocephalic, with normal hair distribuition. No lymphedenopathy present in occipital, periauricular, postauricular, tonsilar, submandibular, subtonsilar, anterior chain, posterior chain, and supraclavicular lymph nodes. Patient can’t hear out of left ear. Both ears have compacted cerumen present. Patient does not wear corrective lenses, and could not see the eye chart to assess visual acuity. His eyes react slower than normal to light, but EOM are bilaterally intact. Patients’ mouth is moist, with a few teeth missing on top and bottom, and no signs of central or peripheral cyanosis. No carotid bruits, no jugular venous distention, and the trachea is midline. The thyroid is non-papable.

Lung: Chest is symmetrical, with diaphragm excursion 6 cm bilaterally. Left lung field breath sides decreased compared to the right lung field. There is also wheezing heard in the right lung field. Right lung field is resonant to percussion, but the left lung field is dull to percussion. Vibrations felt throughout for tactile vocal fremitus. No crackles or rales heard.

Heart: No thrills, murmers, bruits over the carotid, or extra heart sounds heard. Rate and rhythm are regular, and also symmetric at radial, femoral, dorsalis pedis and posterior tibial pulses. S1 and S2 heard in all regions.

Abdomen: Scar preset from a stomach tube that was placed for feeding. Patient doesn’t recall when or why the tube was placed. Chart did not specify why either. No bruits heard over the abdominal aorta, renal, or iliac arteries. Borborygmus present. No tenderness, guarding, or rigidity present. There are bulging flanks and spider nevi present. Liver span is 6 cm. Spleen and kidneys non-papable. i

Extremities: Patient has weak dorsalis pedis and posterior tibial pulses present (1+ bilaterally). Ankles are swollen, there is no pitting edema present.

Musculoskeletal: Lower extremities have normal passive ROM present, but decreased active ROM. Normal passive and active ROM present in upper extremities. Motor strength is decreased in upper(4/5) and lower limbs(3/5).

Nervous System:

Mental Status: Patient is alert and oriented to place and time, but cannot remember events from yesterday. He can remember events from years ago, and is aware that he is forgetful now with memory loss.

Cranial Nerves: Intact, no facial dropping or weakness on either side.

Sensory: Lower extremities showed pain sensation and proprioception intact, but no vibration sense present.

Reflexes: Lower extremity reflexes were not assessed as patient could not move his legs. Upper extremity reflexes intact.

Cerebellar: Babinski intact. Patient could not get out of bed to assess gait.

Laboratory Data: Labs taken Dec. 31, 2010

Glucose elevated 122 (normal 70-105 mg/dL)

BUN/Cr elevated 1.35 (normal 0.7-1.3 mg/dL)

Problem List:

1) Dementia

2) Chest pain

3) Wheezing and Cough

4) Depression

5) Leg/Arm weakness

6) Preventative medicine- routine physical exam, mini mental status exam, psych evaluation, colonoscopy and rectal exam, pneumovax vaccine, influenza shot

Assessment:

Dementia: Dementia is an impairment of cognitive function, affecting memory, attention, language, and/or problem solving. This impairment has to be lasting 6 months or longer. The first sign of dementia is usually short term memory loss, progressing to memory forming impairment, and later an inability to learn new things. Usually the patient is aware of the memory loss. Eventually the memory loss is too great, and there is a loss of personal hygiene, eating, and other activities of daily living. This also affects mood, and there can be fluctuations between happiness, sadness, and anger. There can be sleep disturbances and personality changes. Depression is one of the major illnesses that can present with dementia. Lastly, there is a complete dependence on others, as the patient can no longer take care of themselves, is disorientated, has memory loss, and in many cases, cannot swallow properly.

There are many types of dementia, and once a person has met the requirements to be diagnosed with dementia, the type must be determined. Each type is caused differently, so treatment can vary slightly. The most common type is Alzheimer’s dementia. Patients with Alzheimer’s can be differentiated from other types, as these patients are more likely to get lost in familiar places, try to leave home, have difficulty communicating, and have memory problems. This can occur from tau neurofibrilllary protein tangles in the brain and plaque formation. Also there can be a loss of acetylcholine in the brain. Patients with multi-infarct dementia can be differentiated based on a history of smoking, stroke, atherosclerosis, and hypertension. Multi-infarct dementia occurs from many small strokes affecting the brain. Patients with vascular-type dementia usually have aphasia, apraxia, a difficulty learning math skills, and often present with neglect. This type of dementia occurs due to cerebrovascular disease or stroke. Lewy-Body dementia presents with recurrent visual hallucinations, motor impairments similar to Parkinson’s disease, and varying levels of attention throughout the day. This can occur due to Lewy bodies (abnormal protein) deposits in the brain, and sometimes a loss of dopamine too.

Currently, our patient has been diagnosed with dementia. He meets the criteria for this diagnosis: he has memory loss, is aware of his memory loss, has lost the ability to care for himself, has lost some autonomic function and must wear a diaper, and has been having sleep disturbances. Mr. AS does not recall how he got to the facility, and states that he can’t remember what he did yesterday, but can remember stuff from years ago. He no longer can live alone at home without someone to care for him, and has been living at the facility since April 2009. He also states that he sleeps more than he used to, sleeping now for most of the day. A family member must be contacted to assess the changes that have occurred prior to his admittance to the facility, as our patient is unable to tell us of any changes in his status. We also need to contact his family to narrow down which possible type of dementia the patient has based off of his previous behavior prior to entering the facility. If he was experiencing getting lost in familiar places, it could be Alzheimer’s; he has the risk factors of multi-infarct dementia, especially if he has had more than one stroke; lastly we would need to assess his function before and after the stroke to determine if it was vascular type dementia. He currently has no signs or symptoms of Lewy- body dementia. Our patient is also on medications for Alzheimer’s type of dementia: Mirtazapine, Namenda, Aricept, and Zolpidem tartrate. These medications help relieve some of the symptoms that our patient has, such as depression and sleep disturbances, and can increase the acetylcholine levels in the brain.

Chest Pain: Chest pain can be caused by angina, coronary spasm, MI, pericarditis, gastroesophageal reflux, aortic dissection, and many more causes. Our patient is not currently in any chest pain, but he does have a pace maker. He states he does not know why he was given a pace maker, but states that he has never had any problems or complications with it. A family member needs to be contacted to find out why the pace maker was placed. His chart did not state a reason for the pace maker or state why he was having chest pain. The most common reason for a pace maker is to regulate an arrythymia. An EKG record prior to his placement of his pace maker, can help to determine if an arrhythmia was the reason he had one inserted. A recent EKG will tell us if his heart rate is normal, and if there are any associated pathologies. His medications include: Nifedipine, Metoprolol tartrate, and aspirin, which are all given for chest pain, usually angina and hypertension. He is also taking Omeprazole for GERD.

Wheezing and Cough: The most common cause of wheezing is due to a constriction of the airways. This can be an inflammatory response, such as with asthma. Asthma, however, would also cause shortness of breath, which our patient is currently not experiencing, and would be bilateral (unlike only in one side as with our patient). COPD, emphysema, or a lung tumor could be possible causes for his wheezing and coughing. Smoking is a risk factor for all 3, and our patient has a 160 year pack history. It needs to be determined if his wheezing is occurring in the expiratory phase or the inspiratory phase. During the expiratory phase would indicate bronchial disease, but during the inspiratory phase would indicate a foreign body (such as tumor) or scarring. Wheezing heard in both phases could indicate a collapsed lung or portion of lung. Unilateral wheezing also would be more indicative of a lung tumor. There also are no crackles or rales heard in our patient, so fluid in the lungs or turbulent flow does not seem to be the problem.

Depression: The cause of depression is unknown, but it is known to be caused by chemical imbalances in the brain. It can also be caused from stress, or a life changing event, such as death of a loved one or social isolation. Depression can present with a number of symptoms such as: fatigue, lack of energy, feelings of worthlessness, feelings of hopelessness, anger, discouragement, irritability, changes in appetite, changes in weight, sleep disturbances, and thoughts of death or suicide. Although our patient has had sleep disturbances, a SIGECAPS interview was negative. His sleep disturbances can be due to dementia. Currently our patient is on medication for depression, Mirtazapine, and should remain on it, so that he does not become depressed.

Arms and Leg Weakness: Arm and leg weakness can be caused by a number of things, such as stroke, infectious disease, amputations, and trauma. Our patient suffered a stroke, after which he states he has not been able to use his legs anymore. His legs may be weak, as the nerves may have been damaged from occlusion, and are not able to send complete signals anymore. His arms may be weak from overuse, as he has been learning to use a walker as part of his physical therapy. His arms have to hold up his body now, as his legs can’t.

Preventative Medicine: Our patient needs to have continuous routine physical exams to assess his ever changing status. A mini mental status exam also should be performed to monitor any changes, or the rate of progression of his dementia. A psych evaluation is needed to determine the extent of his depression and if it is getting better from his medication, or if he is having a more positive outlook on life. Our patient is at the age where a routine colonoscopy and rectal exam should be performed to monitor for colon cancer, prostate cancer, and BPH. Currently our patient is on Tamsulosin for BPH, so it is essential to continually monitor him. Additionally, our patient is elderly and should have a pneumovax vaccine and an influenza shot as prevention for illness.

Plan:

In addition to the preventative measures listed, in order to assess the patient fully, we will need to contact his family and inquire about if there were any changes in the patient’s mood, demeanor, physical abilities, and mental status before he was admitted to the facility. His family will also be questioned about their family history of disease, as the patient could not recall how most of his family passed away. To prove our diagnosis, brain scans (CT and MRI) should be performed on the patient and assessed for changes, loss, or infarcts. The patient is also experiencing a constant cough, with a 160 pack year history of smoking so pulmonary function tests should be performed. A chest xray should also be performed to determine if there are any pathological changes within his lungs (such as a tumor) that are causing his wheezing and decreased lung field sounds. This xray can also be used to assess if there have been any cardiovascular changes. Due to the patients past history, he will need to be continually monitored for changes. He will also need a CBC to monitor these changes. The patient also will need to have his medication list continually reassessed (additions or deletions) with changes. Currently he is on medication for allergies or rhinorrhea, but he is not experiencing any symptoms of allergies or rhinorrhea, so Loratadine and his nasal decongestant may be removed.