This 87-year-old man presents today at my request because he is not feeling well. He left
a voicemail on my assistant's phone today, wondering about his recent blood tests
because he has not been feeling well. He is vague in what way he does not feel well. He
says he is mildly nauseated, he is achy, he is weaker. He states he was at El Camino
Hospital ER a few days ago with chest pain. They put him on a nitroglycerin patch,
which he is now wearing, and the chest pain has resolved. He thinks it was angina.
He has been checking his blood sugars and they have been generally okay. His recent
hemoglobin A1c was 6.5. It is not clear what medications he is on. He is sure he is
taking Lotensin, Prilosec, folic acid, glipizide, and Ambien. He does not think he is on
the Norvasc anymore. He is now on a Nitro-Dur patch 0.2 mg. He sleeps well with the
Ambien. He uses one pillow. He has been having no swelling of his ankles. He is not
on aspirin. He denies any vomiting. His weight is pretty stable. His bowel movements
are fine. He has numb feet. He denies any urinary symptoms. His appetite is not great.
He is still living with his niece who is quite attentive. His daughter lives on the East
Coast now and his sons are local but, as he puts it, they are too Americanized.
He is not coughing. He does not have a sore throat. He feels his vision is fine, last had
an eye exam within the past year.
PHYSICAL EXAMINATION:
VITAL SIGNS: His blood pressure is 150/70, pulse 80 and regular, temperature 98.3.
His O2 sat was 97-98 percent on room air. Weight 182 pounds.
GENERAL: He looks chronically ill. He came in a wheelchair similar to a year ago but
was able to get up on the scale and up on the exam table with only a little bit of
assistance. He is quite slow, however. His speech is normal for him, slow and
deliberate. He understands.
HEENT: His ears are clear bilaterally. His throat is clear.
NECK: Without adenopathy, no thyromegaly, JVD, or bruits.
CHEST: Clear to A and P.
HEART: Regular S1, S2, without murmurs, rubs, or gallops.
ABDOMEN: Normal bowel sounds, soft, nontender without organomegaly or masses.
He does smell slightly of urine.
EXTREMITIES: His pedal pulses are diminished. There is no edema. He does have
onychomycosis and some tinea pedis. Sensation is absent to microfilament.
His chest x-ray was negative and better than before. His EKG was unremarkable and
unchanged. His UA was clear. A sed rate and TSH are pending.
IMPRESSION: Weakness and fatigue. I think this is primarily part of the aging process
and the natural history of his multiple medical problems. I do not know that there is
anything reversible.
PLAN:
1.
We will get his records from El Camino.
2.
3.
4.
He will return for followup in one month and will bring all of his medications
with him.
He is going to schedule an echocardiogram.
I have reviewed all the results of his labs with him.