Patient Presentation

ID: Mr. Dawson is a 67 y/o male residing in the VA LTC since 4/2016. He was admitted due to cognitive decline and being unsafe at home alone.

Informant: self and medical records. Pt. has a h/o dementia so is a somewhat unreliable historian

CC: “My throat hurts when I eat” x a few days

HPI

67 y/o obese male with a PMH of schizophrenia, HTN, PTSD, COPD Dementia, secondary polycythemia, BPH, OA, seizure disorder, HLD and CAD complains today of occasional burning pain in his chest. Pt. states worsening, intermittent burning sensation in his chest has been going on for a while, but now he has sharp pain in his throat when he swallows solid food (but not so much with liquids unless they are very hot) for a few days. He reports that pain in his chest worsens at night and makes him feel “like I’m hungry”. This also occurs when he takes a nap after lunch. He states the chest pain is non-radiating, non-pleuritic, and not affected by respiration. He denies sore tongue. There is no nausea, vomiting, diarrhea, SOB, diaphoresis, bloating, cough, dizziness, syncope, DOE, fever, chills, dyspnea, or headache.

Working Differential Diagnosis

· GERD

· Esophageal stricture

· Esophagitis – a lot of medications (esp for OA)

· R/O cardiac issues

· Esophageal cancer

· Barret’s esophagus

 

PMHx:

• HTN
• CAD
• COPD
• Seizure disorder
• Polycythemia (secondary to COPD)
• BPH
• HLD
• OA
• Dementia
• Schizophrenia

No past surgical Hx

Family Hx: – Declines to give any

Social Hx – Used to live alone until he developed cognitive deficits and the living situation became unsafe. Sister is next of kin who lives about 10 blocks away. Smokes 1 cigarette/day for last 4 years, but used to smoke 1ppd (40 pack-years history). Denies any ETOH/Illicit drug use. Pt. is independent with all ADLS, transfers and ambulates without any assistive devices.

Served in Vietnam 1971-1972. Later diagnosed with PTSD

Allergies: PCN à rash

ROS:

HEENT: Denies ear pain, hearing changes, facial pain,

As previously noted, c/o dysphagia for solids and hot liquids, but not cool liquids

Neck: denies stiffness or swelling/swollen glands

CVS: Endorses intermittent burning chest pain, especially at night without dyspnea, SOB, or radiation

Pain not associated with respiration, but worse when supine at night and when napping in afternoon.

Pain accompanied by sensation of hunger. No DOE, palpitations, ankle swelling, PND, Orthopnea

Pulmonary: Denies SOB, dyspnea, cough

GI: occasional constipation. No N/V/D, abdominal pain, changes in BM, bloating, anorexia, blood in stools, hemorrhoids

GU: Admits frequency, hesitancy, and dribbling. Denies incontinence, dysuria, nocturia, urgency, flank pain, hematuria, urethral discharge

MSK: Reports multiple joint pains with chronic OA – especially knees and shoulders which he attributes to working in construction for many years carrying heavy materials. Pt. is taking ibuprofen for joint pain which helps minimize the pain.

Neurologic: Denies memory issues. Endorses long H/O seizure disorder, but no seizures in many years. Denies HA, dizziness, slurring speech, paresthesia, paresis, tremors

Psychiatric: Long h/o schizophrenia- followed in psych clinic. Also has diagnosis of PTSD, but status of symptoms now is unclear. Denies depression, anhedonia, nightmares, suicidal or homicidal ideation.

Endocrine: Denies cold/heat intolerance, polyphagia, polydipsia

Heme: Denies fever, jaundice, fatigue, generalized weakness, easy bruising or bleeding

PE:

VS: T 98.2, oral, HR 86bpm, regular, RR 19 unlabored, BP 143/93 seated, left arm, SpO2 95% on RA, Ht 74”, Wt 287 lbs, BMI 36.8 – hasn’t changed in 6 months

Gen: Well-developed and obese male. Alert and oriented x 3, NAD, Compliant to exam. Dressed and groomed appropriately

Skin: Warm and dry, good turgor

Head: NCAT

Eyes: clear sclera and conjunctivae, PERRLA, EOMs full without nystagmus

Ears: hearing intact to whisper test, clear canals. Slight cerumen present in both canals, but TMs visualized and without lesions.

Mouth/Throat: Oral mucosa moist and pink. Missing two premolars. Mild periodontal disease noted. Tonsils are normal in size, free of exudates. Oropharynx normal. Tongue midline. Uvula rises symmetrically, tongue protrudes in midline

Neck: supple, no JVD, No thyromegaly, no adenopathy. Carotids 2+ without bruits

Heart: RRR, Normal S1 and S2, no M/R/G

Lung AP-Lat diameter increased, Clear on inspiration, but with slightly prolonged expiration and mild wheezing at end-expiration bilaterally when asked to blow a deep breath out, no accessory muscle use

Abd: Large, soft, non-tender. No masses, lesions, or pulsations noted. No organomegaly. Liver edge firm. No guarding or rebound tenderness

GU: No inguinal adenopathy, no suprapubic tenderness. Genital and rectal exam deferred Why is this a problem in this patient?

MSK: Grossly normal with good ROM all 4 extremities. No joint swelling or deformity Is this an adequate exam of this system in this patient? What simple test could be done to get a general functional sense?

Neuro: MMSE (22/30); Difficulty with Serial 7’s (unable to continue after 2nd number), failed recall of 3 subjects. Not able to write a sentence with a noun and a verb

CN: as above. Also V1-V3 intact, no facial asymmetry, equal elevation of palate, SCM/Trap 5/5

Motor: normal bulk and tone. Strength symmetric, decreased knee extension and ankle dorsiflexion bilaterally. No tremors. No pronator drift

Sensory: to pinprick intact all 4 distal extremities

DTR’s: 2+ throughout. No clonus. Toes down-going

Coordination: No dysmetria noted on Finger-to-Nose

Gait normal

Extremities: No edema, clubbing, cyanosis