Well structured and good capture of information.  Good sequence in the HPI.  Needs a little more info about her loss of appetite and weight loss. Also need to include additional info about areas of concern in this particular patient – e.g. direct and consensual pupil reaction in the L eye, condition of feet, some additional neuro testing (see my comments).  As we discussed, there are other measures that might possibly improve her intake and mood at the same time (more below).  Always need to consider meds as an etiology of mood and appetite changes.  You’ve mentioned that, but how could it be reflected in your plan?                                                     

Identifying Data:

Age: 81 y/o

Sex: Female

Date of encounter: July 6th, 2022

Location: Metropolitan Hospital Geriatrics Outpatient Clinic

Race: Hispanic

Source of Information: Self

Reliability: Reliable

 

Chief Complaint: “I don’t have an appetite” x 3 months

 

History of Present Illness:

Pt is a 81 y/o female, living in her 6th floor apartment alone, ambulates without assistance, independent in ADLs, with PMH of non-proliferative diabetic retinopathy(left), HTN, type 2 diabetes mellitus, HLD, left carotid stenosis (<50%), CKD stage 3, presenting to the clinic for routine follow up. Patient complains of poor appetite for the last 3 months, occuring every day, without alleviating or exacerbating factors. She states she is “just not hungry,” and that she will have a cup of coffee with sugar-free biscuits about 3-4x a day. She does not have an appetite to eat other, cooked meals, as she did in the past. Patient does mention feeling “a little depressed” due to her medical issues, primarily her diabetic retinopathy and HTN. She also notes feeling more sad because her cat of 16 years died 2 years ago, and now the pt feels even more lonely when her daughters are not around. Otherwise she denies nausea, vomiting, abdominal pain, dizziness, headaches, diarrhea, constipation, blood in the stool, suicidal/homicidal ideations, sleep disturbance, cough, CP, SOB, palpitations. Of note, glucose sticks at home have been in the 100s. No new medications, vitamins/supplements/herbs since the last visit. Would like to include the actual weight loss here or question about how clothes are fitting. Also the loss of appetite is a good place for the “um hmm, tell me more” technique.  Asking about favorite foods and whether they appeal is also another way in to a more complete conversation.  Also want to know if there is any pain on chewing or any difficulties with swallowing.

 

Geriatrics Assessment:

ADLs: Independent in all.

iADLs: Needs assistance with shopping.

Visual impairment: Yes – Hx of NPDR bilaterally, left>right

Hearing impairment: None

Falls in the past year: None

Assistive devices used: None

Gait impairment: None

Urinary incontinence: None

Fecal incontinence: None

Osteoporosis: None. DXA 08/19/2019: AP spine T score 0.3, Dual femur T score -0.8

Cognitive impairment: None. Mini-Cog 5/5

Depression: Mild (see PHQ9 below)

Home safety issues: None

Healthcare Proxy: Patient’s daughter (full info in Epic chart)

Advance directives: Patient would like to be full code, but would decline any transfusion or transplant (she is a Jehovah’s Witness).

 

PHQ9:

Little interest or pleasure in doing things? 0/3pts

Feeling down, depressed, or hopeless? 2/3 pts

Trouble falling or staying asleep, or sleeping too much? 0/3 pts

Feeling tired or having little energy? 1/3 pts

Poor appetite or overeating? 3/3 pts

Feeling bad about yourself or that you are a failure or have let yourself or your family down? 0/3 pts

Trouble concentrating on things, such as reading the newspaper or watching television? 0/3 pts

Moving or speaking so slowly that other people could have noticed? Or so fidgety or restless that you have been moving a lot more than usual? 0/3 pts

Thoughts that you would be better off dead, or thoughts of hurting yourself in some way? 0/3 pts

Total score = 6 pts (mild)

 

 

Past Medical History: If known, date diagnosed is helpful

Type 2 Diabetes Mellitus

Hyperlipidemia

Hypertension

Vitamin D deficiency When and how low?

Non-proliferative diabetic retinopathy, left eye- Pt has been receiving intravitreal avastin injections with her ophthalmologist. (x3: 1/25/2022, 5/3/2022, and 6/7/2022)

Carotid stenosis, left – (last carotid duplex in 08/2021 demonstrated <50% stenosis of the left carotid bifurcation with mild homogenous plaque. Plaque is smooth. No dissection. Otherwise left and right vertebral arteries with antegrade flow. No other significant stenosis, thrombus, or dissection demonstrated.)

Chronic Kidney Disease (stage 3, worsening)

 

Immunizations – Due for 2nd COVID booster vaccine and 2nd Shingrix vaccine. Otherwise up to date.

Last mammogram 10/13/2019 negative. Pt is not interested in having any repeat mammograms at this time.

Last colonoscopy done at outside facility in 2018. Patient states results were normal.

Denies recent hospitalizations.

 

Past Surgical History:

Appendectomy – 1995 (done in home country of Spain)

 

Medications:

Metformin 500mg – 2 tablets PO in the AM and 1 tablet in the evening (1500mg total/day)

Amlodipine 5mg – 1 tablet by mouth daily

Lisinopril 10mg – 1 tabley by mouth daily

Atorvastatin 10mg – 1 tablet by mouth daily

Cholecalciferol 1,000 units – take 1 tablet by mouth daily

 

Home and current medications were reviewed and reconciled. Home and EHR meds were the same.

 

Allergies:

Denies any known drug, environmental, or food allergies.

 

Family History:

Mother – deceased at 80 y/o, medical history unknown.

Father – deceased at 74 y/o, medical history unknown.

Sisters – 83 y/o, 76 y/o – both alive and well. Both with DM2 and HTN.

Denies history of cancer.

 

Social History:

Pt lives by herself in her apartment on the 6th floor which she accesses through the elevator in her building. She is retired and widowed. Pt is able to complete ADLs and most iADLs independently, although she states she needs assistance with grocery shopping, which is done by her daughter weekly. Patient states her two daughters visit her often and love her very much. She also speaks on the phone with her siblings in Spain almost every day. Pt also enjoys attending a bible study class several times a week.

Habits – Drinks 3-4 cups of caffeine daily. Denies smoking history. Denies alcohol use. Denies history of illicit substance use.

Diet – Poor appetite. Pt usually has a cup of coffee with small biscuits for her meals.

Exercise – Pt states she is very active and able to walk >5 city blocks without having to stop or experiencing SOB or CP. Always good to ask about stair-climbing too

Sleep – No complaints. Patient sleeps about 8 hours every night.

Travel – No recent travel.

Sexual Activity – Denies currently. Pt states she was last sexually active >15 years ago.

 

Review of Systems:

General – (+)weight loss. (+)decreased appetite. Denies recent fever, chills, fatigue, night sweats.

Skin/nails – Denies rash, new moles, erythema, change in pigmentation, changes in hair distribution.

Head – Denies headache, dizziness, lightheadedness, recent head trauma.

Eyes – (+)visual disturbance (blurred vision) left>right. Denies photophobia, itchiness, redness, tearing, or discharge. (+)glasses use.

Ears – Denies change in hearing, tinnitus, otalgia, discharge. No hearing aid use.

Nose – Denies congestion, discharge, epistaxis.

Mouth/throat – Denies sore throat, difficulty swallowing, bleeding gums, dryness, swelling.

Neck – Denies pain, stiffness, limited ROM, lumps.

Pulmonary – Denies SOB, DOE, cough, wheezing, cyanosis, orthopnea, hemoptysis. Sleeps with 1 pillow for comfort.

Cardiovascular – Denies chest pain, palpitations, lower extremity swelling, syncope.

GI – Denies abdominal pain, nausea, vomiting, diarrhea, constipation, excessive belching, rectal bleeding. No recent changes in BM.

Genitourinary – Denies dark urine, incontinence, urgency, dysuria, hematuria, frequency.

Nervous –Denies tingling, seizures, confusion, weakness, numbness, gait change.

Musculoskeletal – Denies body aches, back pain, joint pain, claudication.

Hematologic – Denies history of DVT/PE, blood transfusions, bruising.

Endocrine – Denies polydipsia, polyphagia. Denies heat or cold intolerance.

Psychiatric – (+)”mild” depression. Denies suicidal thoughts or hallucinations.

 

Physical Exam:

Vital signs:      BP: Seated                  L-arm: 135/60

RR:      16 breaths/min, unlabored

Pulse: 81 bpm, regular

T:        98.8 degrees F (oral)

O2 Sat: 99% on room air

Height: 5 ft 0 inches        Weight: 135 lb.       BMI: 26.37

^8 lbs less than weight on 6/7/2022 (143 lb.)

OB status: postmenopausal

 

General: Pt alert, oriented. No acute distress. Well nourished. Elderly. Well dressed/groomed.

 

Skin: Skin is warm. Poor skin turgor (pt is elderly). No ecchymosis. (+)many small hyperpigmented, light brown macules along arms and dorsum of hands, consistent with solar lentigines. Nonicteric, no other lesions noted, no tattoos. No rashes appreciated. Skin of feet – either here or in a separate section on Extremities (because patient is a diabetic)

 

Hair: well distributed, no signs of female pattern baldness.

 

Nails:  no clubbing, capillary refill <2 seconds in upper and lower extremities.

 

Head:   normocephalic, atraumatic, nontender to palpation throughout. No evidence of previous falls. No abnormal facies.

 

Eyes – Eyelids without lesions, edema, or discharge. No strabismus, exophthalmos or ptosis.  Sclera white, conjunctiva pink bilaterally. PERRLA. Would like to comment specifically on whether there is any delay contraction of L pupil – direct or consensual light.  Lens without cloudiness/opacity bilaterally. EOMs intact with no significant nystagmus.

Fundoscopy – Red reflex intact OU

Visual acuity corrected (glasses): 20/40 right, 20/60 left, 20/50 OU.

 

Ear: Symmetrical and appropriate in size.  No lesions, masses, trauma on external ears. No mastoid tenderness b/l. (+)Mild amount of cerumen in right auditory canal.  Right TM pearly white and fully intact with cone of light in good position. (+)left canal with moderate amount of cerumen, obscuring view of the TM. No discharge or other foreign bodies in external auditory canals. Auditory acuity intact to whispered voice bilaterally. I think we discussed that cerumen is not necessarily a problem, but would like to know if you can see the TM at all (so canal is still patent) or whether the cerumen is dry, “impacted”.

 

Nose – Symmetrical. No masses, lesions, deformities, trauma, discharge, tenderness, stepoffs.

Nares are patent bilaterally. Nasal mucosa pink & well hydrated. No discharge noted on

anterior rhinoscopy. Septum midline without lesions, deformities, injection, perforation.

No foreign bodies.

 

Mouth/Oropharynx – Lips appear pink and moist, with no masses, cyanosis, or ulcers. Mucosa pink and moist. No lesions or masses. No leukoplakia. Palate pink, moist, intact with no lesions, masses, or scars. No gingival hyperplasia or recession. Top and bottom dentures in place.

Tongue is midline. No discharge, masses or lesions.

Uvula is midline and rises symmetrically with phonation. No edema or lesions.

Oropharynx is pink and moist. Tonsils are symmetric and without hypertrophy. No swelling, erythema, exudates, masses/lesions, or other foreign bodies.

 

Neck – Full ROM. Supple. Non-tender to palpation. No JVD. Trachea is midline. No masses or lesions. No scars. Lymph nodes non-palpable bilaterally. No stridor. 2+ carotid pulses bilaterally. No cervical adenopathy noted. Thyroid is non-tender with no palpable masses. No thyromegaly.

 

Chest/Pulmonary: Chest is symmetrical, without deformities or trauma. Lat to PA diameter is 2:1. Respirations unlabored. No use of accessory muscles noted. Chest nontender to palpation throughout. Lungs CTA bilaterally. No wheezes, rhonchi, rales, or other adventitious sounds. Chest expansion is symmetric.

 

Heart: Regular rate and rhythm. Distinct S1 and S2. No murmurs, S3, S4, friction rubs, or splitting of S2 appreciated. PMI in 5^th ICS in mid-clavicular line.

Carotid pulses are 2+ bilaterally without bruits. JVP is <2cm above the sternal angle with head of the bed at 30°.

 

Abdomen: Abdomen nondistended, symmetric. (+)~1cm transverse scar to the suprapubic region, midline, well healed. No striae, pulsations, or hernias visibly noted. Bowel sounds normoactive in all 4 quadrants. No renal, iliac, or femoral bruits. Tympanic throughout. Abdomen is soft, nontender to palpation, no guarding or rebound. No hepatosplenomegaly. No CVA tenderness noted. Liver span and edge in this patient

 

Mental Status: Appearance and behavior – patient alert, no abnormal movements, grooming/hygiene appropriate. (+)pt is tearful when speaking about the passing of her cat and feeling lonely. Otherwise appropriate facial expression and manner.

Speech and language – follows 2 stage commands. Is able to repeat words and name objects. Speech is of appropriate quantity, rate, volume, flow, and articulation.

No SI/HI, no feelings of rage or anxiety.

Conversation progresses logically towards a goal. No delusions, hallucinations, phobias, obsessions.

Oriented to name, date, time, location. Mini-Cog 5/5.

 

 

Neurologic:

Cranial Nerves –See “Eyes” for CN II assessment. Conjugate gaze without nystagmus. Convergence of eyes. No ptosis. Symmetric and fluid facial movements. No difficulty with BMP speech sounds. Soft palate rises with “ahh” and uvula remains midline. No hoarseness or nasal quality in voice. No facial droop. No difficulty with LTND speech sounds.

 

Peripheral Neuro –

Motor/Cerebellar

Symmetric muscle bulk with appropriate tone for age. No atrophy, tics, tremors or fasciculation. Strength 5/5 throughout, including flexion and extension of knee, hip, and elbows bilaterally. Full active/passive ROM of all extremities without rigidity or spasticity. Rhomberg negative, no pronator drift noted. Gait steady with no ataxia.

 

 

Musculoskeletal: No soft tissue swelling / erythema / ecchymosis / or deformities in bilateral upper and lower extremities. Non-tender to palpation throughout. (+)crepitus noted with flexion and extension of bilateral knees (pt denies pain). FROM (Full Range of Motion) of all upper and lower extremities bilaterally.  No evidence of spinal deformities or spinal tenderness to palpation.

When there is retinopathy and nephropathy, there may also be neuropathy so it would be important to test sensation to sharp and vibration – especially in the feet.  Also need DTRs and plantar reflexes to complete the neuro exam in someone of this age.

 

 

—————————————————-

 

 MOST RECENT LABS

 

Vit B12, 2/22/22

376 (ref range 232-1245 pg/mL)

 

Lipid Panel 3/30/22

Total cholesterol 150

HDL 46 L

Triglycerides 128

LDL 78

 

TSH 3/30/22

4.20

 

CBC (5/3/22)

WBC 8.6

Hgb 10.8 L (stable compared to previous lab draws)

Hct 32.4 L  (stable compared to previous lab draws)

MCV 90.8

MCHC 33.3 L

MPV 10.3

RDW 13.0

Plt 283

Remaining CBC WNL

 

CMP (07/01/2022)

Sodium 141                                                                             Calcium 9.2

Potassium 4.9                                                                          Anion Gap 17.0

Chloride 103                                                                           Osmolality 295

CO2 22.0                                                                                Albumin 4.6

BUN 22.0 H    (16.0 on 5/3… 19.0 on 3/30)                          Total protein 6.9

Creatinine 1.1 H  (0.8 on 5/3… 0.9 on 03/30)                     Total bilirubin 0.4

eGFR 49.2 (72.2 on 5/3… 62 on 3/30)                                 Alk Phos 79

ALT 18                                                                                   AST 17

Glucose 166

 

Today, 07/06/2022 (Done in the office):

Glucose fingerstick: 182 (pt had breakfast ~1 hr prior)

HgA1c: 6.4% (← 7.0 (on 3/30/22) ←  7.8 (on 9/30/2021))

 

 

 

Assessment/Plan:

81 y/o female, living in her 6th floor apartment alone, ambulates without assistance, independent in ADLs, with PMH of non-proliferative diabetic retinopathy(left), HTN, DM2, HLD, left carotid stenosis (<50%), CKD stage 3 (worsening), presenting to the clinic with complaints of poor appetite x3 months with associated 8 lbs weight loss since the last visit 4 months ago.

 

1. Involuntary weight loss

Due to poor appetite, suspect may be due to mild depression. Other DDx include malignancy, hyperthyroidism, (unlikely due to normal TSH)  GI disorder (gastritis?), poor denture fit, medication adverse effect (metformin, cholecalciferol). How will this be reflected in your plan?

Offered referral to psychiatry but patient is refusing at this time. Discussed return precautions to the ED if pt is having SI/HI or any other concerns.

Advised patient to cut down on coffee (limit to 1/day) and biscuits and to try eating meals rich in protein. Recommended increased physical activity and time outside socializing with her book club and daughters. Pt seems agreeable to plan. BMI is still in the overweight range. Will reassess weight at follow up in 1 month after patient tries eating a more balanced diet and increasing social interactions. As per our discussion, other measures: senior lunch program, asking daughter or others to come for a meal regularly, Glucerna or similar shakes (they make cookies too which are designed to increase nutrition for diabetics).  Meals on Wheels.  Adding extra flavor – such as Mrs. Dash or hot sauce (if she likes that).  Consider supplementing zinc which helps with appetite for some.  Other appetite stimulants.  One concern in this particular patient is that protein not be over-supplemented in view of her decreased kidney function. 

 

2. CKD, stage 3

Worsening creatinine, BUN, eGFR. Will order US kidneys and refer to nephrology for further evaluation.

 

3. NPDR, left

Continue regular evaluation with ophthalmologist. See DM management below.

 

4. Hypertension

BP well controlled in the office today. Continue with lisinopril 10mg and amlodipine 5mg daily. Advised to keep a BP log book when checking BP at home and to bring the log to the next visit.

Counseled pt to cut down on daily coffee intake (limit to 1/day). And make sure to drink something else or she may lose her only hydration source (might seem obvious to you, but possibly not to her).

 

5. Type 2 Diabetes Mellitus

Continue metformin as prescribed. Advised the patient to record her fingersticks at home and bring log to the office at next visit.

 

6. Hyperlipidemia

Lipids at optimal level in March. Continue atorvastatin as prescribed.

 

7. Left carotid stenosis

<50% based on last carotid duplex in 08/2021. Will repeat in August 2022.

Continue statin as prescribed.

 

8. Vitamin D deficiency

Continue supplements. Will recheck value before next visit and reassess need for change in supplementation.

 

9. Other health maintenance

Immunizations- pt will receive second Shingrix vaccine today. She is refusing 2nd COVID booster at this time. Otherwise pt is up to date.

Last mammogram and colonoscopy were negative. Pt is not interested in repeat studies at this time.

Check the following labs before next visit in 1 month: CBC, CMP, Vit B12, vitamin D, TSH)