Source: Resident + information from EMR
CC: Decreased hearing from R ear X 4 days + Complete physical exam
HPI: 83-year-old male with PMHx of thrombocytosis, chronic PTSD, rosacea conjunctivitis, bilateral neurotrophic keratoconjunctivitis of the eyes, dementia, recurrent bilateral LE cellulitis, HFrEF (EF 25-30%), HTN, DMT2 (HbA1c 6.1 – 10/2023), CAD s/p CABG (1995), diverticulitis s/p sigmoidectomy 2006, large ventral/abdominal hernia with failed surgical repair 2007, PUD s/p hospital stay 1/27 – 2/5/24. Resident is complaining about reduced hearing out of his right ear for the past few days. He says there is no pain associated with it. Resident currently denies any fever, chills, headache, nausea, vomiting, diarrhea, constipation, chest pain, shortness of breath or abdominal pain.
Differential Diagnosis
- Cerumen buildup in ear
- Presbycusis
- Bacterial infection
- Viral infection
Past Medical History and Past Psychiatric History
Thrombocytosis
Hypertensive heart disease
Chronic combined systolic and diastolic heart failure
Disorder due to type 2 diabetes mellitus
Chronic post-traumatic stress disorder
Rosacea conjunctivitis
Bilateral neurotrophic keratoconjunctivis of the eyes
Essential thrombocythemia
Exposure to potentially hazardous substances
Chronic congestive heart failure
Dementia
Diverticulosis
Hypertension
Hyperlipidemia
Coronary artery disease
Cranial nerve palsy
Obesity
Past Surgical History
CABG
Sigmoidectomy
Large ventral/abdominal hernia with failed surgical repair
Social History
Past work history – Truck driver for an electronics manufacturer
Sleep – Resident endorses sleeping well throughout the night
Smoking – Denies use
Alcohol – Drank a glass of wine with his wife at night occasionally
Illicit drug use – denies
Family History
Children – (2) daughters and (1) son – alive and well
Allergies
NKA
Immunizations
Influenza – Oct 2024
Covid 19, Pfizer, MRNA, Trivalent – Sept 2024
ROS
General: Denies fatigue, fever, chills, night sweats or weight loss or gain
Skin, Hair, Nails: Denies any change in hair texture, excessive dryness or sweating, discolorations, pigmentations, rashes or pruritus
Head: Denies losing consciousness, headaches, or being lightheaded
Eyes: Denies visual disturbances, blurry vision, fatigue, or lacrimation
Nose: Denies epistaxis, discharge, or any obstructions
Ears: Admits to decreased hearing in Right ear. Denies pain, discharge, bleeding, or tinnitus
Mouth/Throat: Denies dysphagia, bleeding guns, sore tongue, or mouth ulcers
Pulmonary system: Denies orthopnea, dyspnea, wheezing, hemoptysis, cyanosis, or cough
Cardiovascular system: Denies palpitations, heart murmurs, chest pain or feelings of irregular heartbeats
Gastrointestinal system: Denies vomiting, abdominal pain, diarrhea, constipation, changes in bowel habits, or dysphagia
Genitourinary system: Denies incontinence, polyuria or nocturia
Nervous: Denies weakness, headaches, or sensory disturbances
MSK: Denies erythema, back pain, arm pain, leg pain, swelling or arthritis
Psychiatric: Denies anxiety, depression, or difficulty sleeping
Vitals
BP: 102/68
HR: 62
Temp: 97.1 F
RR: 18
Weight: 198 lbs [89.8 kgs]
Physical Exam
General: Male in his mid-80s is lying in bed is awake, alert and in no acute distress
Skin: Some bruising was noted on bilateral arms and on residents left knee. Good turgor. No tenting. Normal body temperature was noted. Non-icteric
Hair: Average quantity and distribution
Nails: No clubbing was seen. Cap refill was under 2 seconds. Atraumatic
Head: Atraumatic, Normocephalic. Non-tender to palpation
Eyes: PERRLA, but resident was noted to have miotic eyes; Extra-ocular movements intact
Ears: Cerumen was noted in Resident’s right ear. No lesions, masses, trauma, or discharge was noted. Normal external pinnae. Hearing intact on left ear. Tragus normal to palpation
Nose: No nasal deformity. No septal perforation. No epistaxis or nasal discharge
Mouth/Throat: Resident endorses denture usage; only top dentures were visualized, No oral mucosal lesions: no oropharyngeal lesions. No tonsillar enlargement. No pharyngeal exudates or erythema
Neck: Trachea midline. Full ROM, no nuchal rigidity; No thyroid enlargement. No swelling
Thyroid: No palpable nodes; Non-tender
Chest: Symmetrical chest rise to palpation throughout; CABG scar was noted with no deformity.
Non-tender
Lungs: Symmetrical expansion with respiration. No intercostal retraction. BS clear to auscultations bilaterally. No rales, wheezes, or rhonchi auscultated.
Heart: S1 and S2 with no distinct murmurs, rubs or gallops. Regular rate and rhythm.
Abdomen: Patient has a left ventral hernia making the abdomen distended, Not tender to palpation and soft. BS normoactive in all four quadrants. No guarding, no masses felt. No organomegaly. CVA non-tender
MSK: Back was non-tender to palpation. No skin lesions were noted
Mental status exam: Resident is well appearing, has good hygiene, and is neatly groomed. Speech and language ability intact, with normal quantity, fluency, and articulation. Resident denies changes to mood. Conversation progresses logically. Insight, judgement, cognition, memory and attention intact.
Neurology: Resident is alert and oriented to name, date, time, and location. Cranial nerves II-XII grossly intact.
Motor/Cerebellar: Full active/passive ROM of all upper and lower extremities without rigidity or spasticity. Symmetric muscle bulk with good tone. No atrophy, tics, tremors, or fasciculation. Strength 5/5 of both upper and lower extremities.
Active Inpatient Medications
Ammonium lactate lotion for dry skin
Aspirin 81 Mg Tablet chewable PO daily
Cyanocobalamin Injection
Empagliflozin Tablet PO 10 Mg daily
Melatonin 3 mg Tablets
Mineral oil/Petrolatum ointment for dry skin
Polyvinyl alcohol for dry eyes
Rosuvastatin calcium 10 mg Tablets
Valacyclovir 1000 mg tablets
Assessment/Plan:
- Decreased hearing in Right ear
– Remove cerumen with irrigation tool
– Use Debrox to soften the cerumen
– Position basin underneath affected ear and place barrier drape on right side of Resident
– Fill syringe with sterile water and place in right ear
– Place syringe in ear and direct water pressure into ear until cerumen is dislodged into basin - Herpes Simplex/Rosacea keratitis/Neurotrophic keratoconjunctivis
– Continue with Polyvinyl alcohol for dry eyes
– Continue with Valtrex
– Resident got Prokera corneal implant placed on left eye and he tolerated it well
– Ophthalmology follow-up appointment schedule for 12/9/2024 - DMT2/Hypertension/Hyperlipidemia: Stable
– Continue with Empagliflozin
– Continue with Aspirin
– Continue with Rosuvastatin
– Continue monitoring Fingerstick blood glucose weekly and record
– Continue monitoring blood pressure and heart rate and record daily
4. Vitamin B12 Deficiency
– Continue with Cyanocobalamin injections
5. Dry Skin/Skin Care: Stable
– Continue with Ammonium Lactate lotion twice daily
– Continue with Petrolatum/Mineral oil daily
6. Anxiety: Stable and not currently on medications
– Allow Resident to adjust to new environments
– Redirect as needed
– Monitor for fall risks
