|Name:SH||Date:February 20, 2018||Time: 3:15 pm.|
|CC: “ I feel lack of energy”|
|HPI: Case of 77 years old, male with his wife complaining of feeling lack of energy asking for vitamins. He said that many times he just doesn’t want to do anything. His wife states he often forgets what he already did par example if he says good morning, he forgets that he just did that and says good morning again. His wife says that he can not take his medication without her supervision because he may take a double dose. He often does not know what day is today. He suffers from high blood pressure taking HCTZ 25 mg daily and BPH on Saw Palmetto 500 mg twice a day and acetaminophen for headaches. He is retired and does not do exercise, the weekends he visits his sons, he drinks a couple of beers weekend and does not smoke. He lives with his wife that is also retired, uses glasses, and has good hearing. He does not cry but feels no interest in things. He said he has a good memory because he recalls his first letter written 70 years ago.|
HCTZ tab 25 mg PO daily
Acetaminophen 500mg for headaches
Saw Palmetto cap. 500 mg PO BID
No environmental or food allergies
Chronic Illnesses/Major traumas
3 Year ago Headache due to Uncontrolled hypertension
|Family HistoryMother Hypertension, Father Heart disease died at 50 and Diabetes Mellitus All other members are negative for Lung disease, Heart disease, Hypertension Cancer, Pulmonary disease Kidney disease Psychiatric diseases, or Tuberculosis.|
|Social History |
The patient is retired from the truck driver he has three sons and one daughter that have their families, One son lives close and expend the weekends with. He watches TV all day and goes with his wife chopping. He uses glasses and drives safely. He is a former smoker and has two drinks a week. He does not read and goes to his country of origin Chile once a year for two months.
|General The patient took no very active in poor appearance, no fatigue, chills, night sweats, remarkable positive drop in energy level reported. Often headaches||CardiovascularNo chest pain, no edema reported, palpitations.|
|Skin Easy skin bruising, no bleeding or skin discolorations, any changes in lesions or moles||RespiratoryHe denies cough wheezing, congested nose or dyspnea,|
|Eye The patient does not use corrective lenses, denies blurring, visual changes||Gastrointestinal No Abdominal bloating no nausea, vomit, no diarrhea.|
|Ears. He denies ear pain tinnitus hearing loss or discharge.||Genitourinary Intermittent loose in urinary flow and strength No dysuria|
|Nose/Mouth/Throat He often feels dry mouth, denies dysphagia, nose bleeds or discharge, no, hoarseness, throat pain||MusculoskeletalLegs pain after long walks no, joint swelling reported stiffness or pain.|
|BreastDenies feeling pain, lumps, bumps, or changes||NeurologicalOften headache No syncope, seizures, transient paralysis, paresthesia, blackout spells|
|Heme/Lymph/Endo Denies, bruising, no night sweats, swollen glands reported, no increase thirst, increase hunger, cold or heat intolerance||PsychiatricDepressed mood loss interest in things|
|Weight 169 lbBMI29.9||Temp96.9 F.||BP145/96|
|Height 5’3”||Pulse68 per minute||Resp16 per minute|
|General Appearance |
Tired looking adulty man in no acute distress. Alert and not fully oriented; answer questions appropriately.
Skin is very dry, multiple hyperpigmented spots in both hands and face. No rashes masses or lesions
|Head Normocephalic, atraumatic and without lesions; no hair Eyes: Pupils equally reactive to light and accommodation. extraocular motor muscles are intact. No conjunctival or scleral injection. No bilateral TMJ swelling click or tenderness to palpation. Oral mucosa is moist Ears: the canal is patent bilaterally tympanic membrane are pearly grey with positive light reflex; landmarks easily visualized. Nose: Nasal mucosa pink No septal deviation. Pharynx with no erythema and no exudate moist mucosa. |
Neck:Supple. Full range of motion; no cervical lymphadenopathy; no occipital nodes. No thyroid enlargement or nodules nu vein distension.
Heart regular rate and rhythm. No extra sounds, clicks, rubs, or murmurs. Capillary refill 1.9 seconds. Pulses 3+ throughout. No edema.
Symmetric expansion, no retractions chest wall. Respirations are regular and easy; lungs clear to auscultation bilaterally.
Abdomen obese peristalsis present to auscultation guarding no rebound tenderness no masses and hepatosplenomegaly no epigastric tenderness
Free from masses or tenderness,
The pelvis is no tender. No nodes. External genitalia according to age and sex.
Full ROM was seen in all 4 extremities as the patient moved about the exam room. No edema no cyanosis pulses present.
Speech clear. Low tone. Posture erect. Balance stable; gait normal.
Alert and oriented in place, not in time does not keep eye contact. Speech is soft, though clear and of normal rate and cadence; answers questions appropriately he repeat questions.
|Lab Tests |
Mini-Mental Score Results in 19 (Low.)
|Special Tests |
- 1- Alzheimer’s. It is characterized as an incurable degenerative disease of the central nervous system with a gradual loss of mental abilities such as memory, speech, and logical thinking (Lin et al., 2013). The risk of its development increases after 65 years. The patient’s wife reports her husband’s forgetfulness and his inability to recall recent events, which is gradually progressing. At the same time, he remembers old events. Also, patients are experiencing problems associated with temporal and spatial orientation, while the choice of words is accompanied by significant difficulties, which, in turn, affects communication as well as contributes to negative personality changes.
- 2- Major depression. A permanent sense of hopelessness and a lack of energy are the main symptoms of major depression (Hayward, Taylor, Smoski, Steffens, & Payne, 2013). The marked reduction of interest in life reported by the patient is another sign of major depression. The given patient answers questions appropriately, yet he cannot establish long eye contact and repeats questions. This shows decreased concentration.
- 3- Multi-infarct dementia. O’Brien and Thomas (2015) state that this disease is associated with vascular changes in brain tissue. Along with a significant decrease in memory, patients may experience getting lost in familiar places or difficulties with following given instructions. Sleep patterns and personal habits tend to be broken, which is not characteristic of this patient.
- Alzheimer’s. The first symptom is that short-term memory decreases with the preservation of long-term memory. Complaints of elderly people of forgetfulness applying for the same information several times are quite typical for the first stages of Alzheimer’s disease (Lin et al., 2013). The second symptom noted by this patient is apathy. The interest in the usual leisure time decreases, and it becomes more difficult to practice a favorite hobby or go out for a walk. As a rule, at this stage, people cope with most household tasks and do not lose their self-service skills, but they may need help in doing the usual things from time to time.
- Hypertension. As shown by the patient’s blood pressure (BP 145/96), he is at stage 2 of hypertension, which creates serious threats to his life by increasing the possibility of strokes and heart attacks. Continuous headaches complicate the situation. The uncontrolled character of hypertension determined earlier and the prescribed medication (HCTZ 25 mg) also supports this diagnosis.
- BPH. The patient has Benign Prostatic Hypertrophy (BPH) and takes Saw Palmetto cap. 500 mg PO BID as prescribed earlier. Pagano, Laudato, Griffo, and Capasso (2014) emphasize the role of Serenoa repens in improving the urinary flow and reducing the frequency of night urination. Characteristic signs of this disease are problems with urination, increased urges, chronic fatigue, and a general lack of energy.
Plan Including test / Therapeutics / Education / No medication treatment
The treatment plan for the patient with Alzheimer’s, hypertension, and BPH should be comprehensive, taking several steps to maintain symptoms and preventing their deterioration. The following tests should be prescribed to the patient: magnetic resonance imaging (MRI) and computed tomography of the head (head CT) to differentiate from other diseases and assess the patient’s condition.
As noted by Iqbal, Liu, and Gong (2014), Alzheimer’s should be taken rather seriously. The fact is that the human brain is plastic enough, and the cells and parts of the brain can partially replace the affected areas, performing additional functions. To provide the brain with the possibility of such self-compensation, the number of neural connections should be high enough, which occurs in people with intellectual activity, hobbies, and a variety of interests. The manifestations of the identified final diagnoses are to be controlled by visiting a physician and a urologist annually, avoiding general hypothermia, and leading an active lifestyle. Proper prophylaxis of BPH and hypertension is a healthy diet (Barry et al., 2017). It is necessary to exclude fast food and limit the use of alcoholic beverages. Furthermore, phytotherapy may also be considered for the treatment of Alzheimer’s in this patient (Fang et al., 2017).
When the disease begins to progress, every opportunity should be used to maintain the patient’s ability to self-service, reduce his isolation from others, and try to prevent the development of depression. For example, better-matched glasses can help for the given patient as he has some problems with vision. The patient himself and his family should be educated to detect signs of Alzheimer’s and report them to a doctor, who will provide further recommendations. The awareness of how to care for the patient will be helpful for the family members.
The patient should conduct self-assessments at home by answering the questions of special tests. For example, the Self-Administered Gerocognitive Examination (SAGE) developed by Ohio State University’s Wexner Medical Center may be suggested. The patient’s family should help him to access the test and understand instructions, yet the test should be completed personally. Any cognitive impairment should be noted by the patient and then reported to his physician. Hypertension and BPH are to be controlled by the patient in a similar manner.
Barry, M. J., Fowler, F. J., O’leary, M. P., Bruskewitz, R. C., Holtgrewe, H. L., Mebust, W. K., & Cockett, A. T. (2017). The American Urological Association symptom index for benign prostatic hyperplasia. The Journal of Urology, 197(2), 189-197.
Fang, J., Wang, L., Wu, T., Yang, C., Gao, L., Cai, H.,… Wang, Q. (2017). Network pharmacology-based study on the mechanism of action for herbal medicines in Alzheimer treatment. Journal of Ethnopharmacology, 196(1), 281-292.
Hayward, R. D., Taylor, W. D., Smoski, M. J., Steffens, D. C., & Payne, M. E. (2013). Association of five-factor model personality domains and facets with presence, onset, and treatment outcomes of major depression in older adults. The American Journal of Geriatric Psychiatry, 21(1), 88-96.
Iqbal, K., Liu, F., & Gong, C. X. (2014). Alzheimer disease therapeutics: Focus on the disease and not just plaques and tangles. Biochemical Pharmacology, 88(4), 631-639.
Lin, F. R., Yaffe, K., Xia, J., Xue, Q. L., Harris, T. B., Purchase-Helzner, E.,… Health ABC Study Group, F. (2013). Hearing loss and cognitive decline in older adults. JAMA Internal Medicine, 173(4), 293-299.
O’Brien, J., & Thomas, A. (2015). Vascular dementia. The Lancet, 386(4), 1698-1706.
Pagano, E., Laudato, M., Griffo, M., & Capasso, R. (2014). Phytotherapy of benign prostatic hyperplasia. A minireview. Phytotherapy Research, 28(7), 949-955.