Chief Complaint: “I couldn’t get up from the couch because my feet were so weak” x4 days ago

History of Present Illness:

            87 y/o F w/ PMHx hypertension, hyperthyroidism, HFpEF, osteopenia, and drug-induced lupus erythematosus 2/2 hydralazine presents to Internal Medicine for b/l foot weakness x4 days ago. According to patient, she fell asleep on the couch around 1:00 PM on Saturday and woke up two hours later unable to get up from the couch because of the foot weakness. Patient attempted to get up multiple times but wound-up sliding off the couch and laying on the floor for about 4 hours before her neighbor saw her and 911 was called. Patient states that weakness is non-radiating and equal in both feet. She describes the weakness as a constant sensation that ants are crawling on her feet and rates it a 8/10 in severity. Patient reports improvement in weakness since admission. Endorses previous episodes of foot weakness of lesser severity. According to patient, she also experienced “a few seconds” of confusion upon waking up where she was unable to recognize her own home and experienced some b/l blurry vision which resolved after she was able to orient herself with her furniture. Patient denies fever, HA, N/V/D, upper extremity weakness, hx of demyelinating disorder, or hx previous intracranial abnormality.

Past Medical History:

Hypertension

Hyperthyroidism

Heart failure w/ preserved ejection fraction

Drug-induced lupus erythematosus due to hydralazine

Osteopenia

Past Surgical History:

Cholecystectomy in 2017 performed at New York Presbyterian Queens

b/l cataract removal in 2014 performed at New York Presbyterian Queens

Hysterectomy performed in 1976 performed at New York Presbyterian Queens

Medications:

***Home Medications***

Losartan 100 mg PO daily for HTN

Hydrochlorothiazide 25 mg PO daily for HTN

Aspirin 81 mg PO daily for cardiovascular risk reduction

Methimazole 5 mg PO every other day for hyperthyroidism

Metoprolol Succinate 100 mg PO daily for cardiac arrhythmia

Potassium unknown dose PO daily for heart failure w/ preserved ejection fraction

Olopatadine HCl 0.7% Solution for Allergic Conjunctivitis

***Medications Prescribed in hospital***

Ceftriaxone IVPN 1 g in 50 mL D5W at 100 mL/hr  administered over 30 minutes every 24 hours starting Wed 02/28/2024 for Urinary Tract Infection

Potassium Chloride packet 40 mEq for Hypokalemia

Allergies:

Hydralazine – caused drug-induced lupus erythematosus

No known food allergies

No known environmental allergies

Family History:

Mother is deceased, PMHx DM and poor diet 

Father is deceased, PMHx “black lung”  (Coal workers’ pneumoconiosis)

Patient has one son and one daughter who are alive and well with no known medical issues

Social History:

G.H. is an 87-year-old widowed female living in Flushing Queens. She does not live with any other people and does not own any pets.

Habits – states she drinks one glass of one during the holidays; denies any history of smoking or illicit drug use

Travel – denies any recent travel

Diet – drinks two cups of coca cola a day; states she has a well-balanced diet and cooks for herself (examples given were red lobster, steamed vegetables, chicken, turkey, potatoes, rice)

Exercise – exercises at senior gym located at residence

Sleep – sleeps 8 hours a night uninterrupted

Safety measures – practices seatbelt safety measures

Sexual Hx – Not currently sexually active

Occupation – representative for the WIC program for 35 years

Review of Systems:

General: Reports weakness. Denies fever, chills, night sweats, fatigue, loss of appetite, recent weight gain or loss

Skin, hair, nails: Denies changes in texture, excessive dryness or sweating, discolorations, pigmentations, moles/rashes, pruritus, changes in hair distribution

Head: Denies headache, vertigo, head trauma, unconsciousness, coma, fracture

Eyes: Reports visual disturbances, uses glasses. Denies use of contacts. Denies fatigue, lacrimation, photophobia, pruritus, last eye exam: September 2023 (normal)

Ears: Denies deafness, pain, discharge, tinnitus, hearing aids

Nose/Sinuses: Denies discharge, epistaxis, obstruction

Mouth and throat: Denies bleeding gums, sore tongue, sore throat, mouth ulcers, voice changes, dentures, last dental exam

Neck: Denies localized swelling/lumps, stiffness/decreased range of motion

Breast: Denies lumps, nipple discharge, pain, last mammogram 2021 (normal)

Pulmonary system: Denies dyspnea, SOB, cough, wheezing, hemoptysis, cyanosis, orthopnea, PND

Cardiovascular system: Reports HTN, unknown irregular heartbeat as per patient. Denies chest pain, palpitations, edema/swelling of ankles or feet, syncope, known heart murmur

Gastrointestinal system: Denies changes in appetite, intolerance to foods, nausea and vomiting, dysphagia, pyrosis, flatulence, eructation, abdominal pain, diarrhea, jaundice, change in bowel habits, hemorrhoids, constipation, rectal bleeding, blood in stool, pain in flank

Genitourinary: Reports incontinence. Denies frequency, color of urine, dysuria, nocturia, urgency, oliguria, polyuria

Sexual history: Sexually active? Not currently sexually active  

Menstrual and Obstetrical: date of last normal period: unknown, menarche: unknown

G:3 T:3 P0: A:0  L:3

Musculoskeletal System: Denies muscle/joint pain, deformity or swelling, redness, arthritis

Peripheral Vascular System: Denies intermittent claudication, coldness of trophic changes, varicose veins, peripheral edema, color change

Hematologic System: Denies anemia, easy bruising or bleeding, lymph node enlargement, history of DVT/PE

Endocrine System: Denies polyuria, polydipsia, polyphagia, heat or cold intolerance, goiter, hirsutism

Nervous System: Denies seizures, loss consciousness, sensory disturbances (numbness, paresthesia, dysesthesias, hyperesthesia), ataxia, loss of strength, change in cognition/mental status/memory, weakness (asymmetric)

Psychiatric: Denies depression/sadness(Feelings of helpless, feelings of hopelessness, lack of interest in usual activities, suicidal ideation), anxiety, obsessive/compulsive disorder, have you ever seen a mental health professional? No Medications: none  

Physical:

General: Patient appears clean & well groomed, alert & oriented to time, place, and person. Has good posture and appears to be a reliable source of information. Appears stated age and is not in acute distress.

Vital Signs:       

Temperature: 98.8

O2 Sat: 98

Height: 4’11

Weight: 115 lbs

BMI: 23.2

Respiratory Rate: 18

Heart Rate: 71

Blood Pressure: 145/66 RT Arm Lying down

Hair, Head, and Face:

Head is normocephalic and atraumatic. Face is symmetrical with no signs of drooping, swelling, or trauma.

Skin, and Nails:

The skin is non-icteric with no swelling or signs of ecchymosis. Nails do not exhibit digital clubbing.

Eye:

The eyes are symmetrical OU

Ear:

Symmetrical and appropriate in size. No lesions, masses, or trauma on external ears.

Nose and Sinus:

The nose is symmetrical without masses, deformities, trauma, or discharge.

Mouth and Pharynx:

The lips are pink with no signs of blisters, fissuring, or cyanosis.

Neck, Thyroid, and Lymph Nodes:

The trachea is midline without masses or scars.

Cardiac:

S1 and S2 are normal. No murmurs, S3, or S4 sounds on auscultation. No S2 split or friction rubs present.

Thorax and Lung:

Chest is symmetrical with no signs of deformity, or trauma. Respirations are unlabored without use of any accessory muscles. Patient has good airflow and no acute findings.

Abdomen:

Bowel sounds normoactive in all four quadrants. Non-TTP, no guarding or rebounding noted. No hepatosplenomegaly to palpation.

Mental Status Exam:

Patient is well appearing, good hygiene and neatly groomed. Patient is alert and oriented to name, date, time, and location. Speech and language ability intact, with normal quantity, fluency, and articulation. Patient denies changes to mood. Conversation progresses logically. Insight, judgement, cognition, memory, and attention intact.

DDx:

1. Peroneal nerve compression
2. Multiple Sclerosis
3. Degenerative spinal disease
4. Guillain-Barré Syndrome
5. New onset cerebrovascular accident

Laboratory Findings:

Na (Sodium) (02/29)	141
K (Potassium) (02/29)	4.4
Cl (Chloride) (02/29)	105
Co2 (02/29)	22
BUN (02/29)	19.5
Creatinine (02/29)	0.76
Glucose (02/29)	103
Anion Gap (02/29)	14
Ca (Calcium) (02/29)	9.1
Lower GFR estimate (02/29)	71
Higher GFR estimate (02/29)	82
WBC (02/29)	5.89
HgB (02/29)	12.5
HcT (02/29)	38.5
PLT (02/29)	194

Urine Culture	Result
Klebsiella pneumoniae (resistant to Ampicillin and Trimethoprim-Sulfamethoxazole)	Positive

Diagnostic Imaging:

CXR 1-View AP Portable

IMPRESSION:

No consolidation, effusion, or pneumothorax. Heart size is unremarkable. Rotator cuff arthropathy bilaterally. Status post cholecystectomy.

XR Pelvis 1-View (AP Only)

IMPRESSION:

No acute displaced fracture or dislocation on this single AP protection. Diffuse osteopenia. The sacrum is obscured by bowel gas. Severe degenerative disease of the lower lumbar spine.

ECG 12-Lead *could not find ECG tracing* 

Component	Result
Ventricular Rate	62
Atrial Rate	62
P-R Interval	152
QRS Duration	116
QT Interval	454
QTC Interval	460
P Axis	21
R Wave Axis	-37
T Axis	90

Assessment:

87 y/o F w/ PMHx hypertension, hyperthyroidism, HFpEF, osteopenia, and drug-induced lupus erythematosus 2/2 hydralazine presents to Internal Medicine for b/l foot weakness x4 days ago. Patient was evaluated for infection and found to have Klebsiella pneumoniae on urine culture for which she is being treated with Ceftriaxone IVPN 1 g in 50 mL D5W at 100 mL/hr  administered over 30 minutes every 24. All other labs and diagnostic imaging performed during admission were unremarkable.

Plan:

#UTI

• Continue administering Ceftriaxone
• Repeat urine culture prior to discharge to ensure eradication of Klebsiella pneumoniae

#bilateral foot weakness

• Continue monitoring patient for improvement of weakness

#HTN

• Continue Losartan 100 mg PO daily
• Continue Hydrochlorothiazide 25 mg PO daily

#Hyperthyroidism

• Continue Methimazole 5 mg PO every other day

#Cardiac arrhythmia

• Continue Metoprolol Succinate 100 mg PO daily

#HFpEF

• Continue Potassium

Patient Education:

            You are at the hospital because of the weakness in both of your feet. We understand that you’re feeling better, but we want to continue monitoring you and try to figure out why this happened in the first place and prevent it from happening again since we don’t want you to fall somewhere and potentially get hurt. While you’ve been here, we checked your urine, and it seems that you have a urinary tract infection, so we’ve been giving you antibiotics to take care of that. You’ll be staying here a few more days until we can figure out what’s triggering this weakness.