History and Physical

History of Present Illness:

51-year-old MALE with history of Gastric Bypass surgery in 9/07 developed increasing
confusion and somnolence 3 months ago. He returned to the Loma Linda VA and was
found to be malnourished. Over the next two months, he progressively improved, with his
confusion and decreased cognitive function slowly returning to baseline. Pt has been
residing in the LL VA nursing facility since his admission for nutritional support via TPN
and observation. Despite improved oral intake, he continues to have difficulty tolerating
his diet and remains malnourished, requiring G-tube placement.

Past Medical History:

Dm Type II
Gout Nos
Obesity
Hypertension
Insomnia
Depressive Disorder
Dyslipidemia
Obstructive Sleep Apnea
Bariatric Surgery
Diabetic Neuropathies
Hypothyroidism
Protein-Calorie Malnutrition
Sensorineural hearing loss of Combined type
Memory loss
Major Depression, recurrent
Panic Disorder with Agoraphobia
Elevated Liver Function Tests
Anemia
Vitamin D Deficiency
Nausea
Cellulitis
Post-nasal drip

Past Surgical History:

9/07 Gastric bypass - complicated by multiple wound infections
2/10 C7 Fracture – while in hospital after a fall

Social History:
NSC Veteral, Disabled
Branch: Navy Service Connected
Combat: Not a combat veteran
Smoking hx: 15 pack/yr history, quit 2 yrs ago
EtOH hx: Occasional use, (2 drinks/wk)
Illicit drug use: Denies
Allergies:
NKDA

Medications:
Ergocalciferol Soln Liquid, 8000 U PO daily, vit D def
Fentanyl topical patch, 1 patch top q72h, pain
Furosemide, Tab 20 mg PO daily, ascites
Metformin, Tab 1000 mg PO BID, Diabetes
Gabapentin cap, 900mg PO TID, pain
Levothyroxine tab 0.075 mg PO daily, hypothyroidism
Magnesium Oxide tab, 420 mg PO BID, hypomagnesemia
Mirtazapine tab 15 mg PO qhs, depression
Oxycodone/Acetaminophen tab, PO q4h PRN, pain
Spironolactone tab, 50 mg PO daily, ascites
Thiamine tab, 100 mg PO daily, bariatric surgery
Trazodone tab, 150 mg PO qhs, insomnia
Zinc sulfate cap, 220 mg PO BID, supplement
Polyvinyl alcohol soln, 1 drop both eyes q6h PRN, dry eyes
Loperamide cap, 4 mg PO BID PRN diarrhea
Loratadine tab, 10 mg PO daily PRN, post-nasal drip
Cyclobenzaprine Tab 5mg PO q8h PRN, muscle spasms

Review of Systems:
General:
YES: Weakness, fatigue, night sweats, chills
NO: Chemotherapy treatment less than 30 days ago, Weight loss-more than 10% body wt
within last 6 month, Radiation treatment less than 90 days ago, Sepsis within last 48
hours, Smoking within last year (15 pack years), fever, heat/cold

Skin:
NO: Open wounds, rash, itching, change in hair/nails

Eyes:
NO: Pain, double/blurred vision, inflammation

Ears:
NO: loss of smell, frequent colds, epistaxis, postnasal drip (+ history, but not recently)

Mouth:
NO: Sores, bleeding gums, hoarseness, dentures, changes in taste

Cardio-Respiratory:
NO: CHF exacerbation or new diagnosis within last 30 days, MI within last 6 months,
Previous PCI (Percutaneous Coronary Intervention), Previous cardiac surgery, Hx of
angina within the last 30 days, HTN controlled with medication, or not, Previous
peripheral vascular interventions, hx amputations, rest pain/gangrene, hx of severe
COPD, ventilator dependency, current pneumonia, CP, claudication, murmurs,
rheumatic fever, persistent cough, hemoptysis, wheezing, SOB, pain on breathing,
peripheral edema, orthopnea, dyspnea, HTN, PND, DOE, palpitations

Digestive:
YES: Change in appetite (appetite improving), Diarrhea (2/2 gastric bypass)
NO: Ascites, esophageal varices, N/V, dysphagia, heartburn, belching/gas, hematemesis,
hematochezia, melena, jaundice, hemorrhoids, constipation, use of laxatives

Genito-urinary:
NO: Acute renal failure, dialysis dependency, dysuria, frequency, nocturia, urgency,
hematuria, incontinence, impotence, testicular pain/swelling, gonorrhea/syphilis

Endocrine:
YES: Hypothyroid, DM I
NO: Prednisone tx, polydipsia

Blood/Lymphatics:
YES: Anemia (hx)
NO: Tranfusions, bleeding/clotting disorders, LN enlargement/pain

Musculoskeletal:
YES: Joint pain/swelling (noted in hands, knees, feet b/l), Stiffness (in hands, knees, feet
b/l)
NO: Muscle cramps

Neurologic:
YES: Poor coordination (noted prior to admission – improving), Memory loss (2/2
malnutrition vs age), Change in sensation (2/2 diabetic neuropathy)
NO: Convulsions, HA, dizziness/fainting, nervousness, weakness/paralysis, coma, no hx
of TIA/CVA

Sleep Disorders:
YES: Apnea (hx – resolved), insomnia (occasional - currently being treated)
NO: Snoring/apnea (currently), excessive sleepiness

PHYSICAL EXAM:
5/27/2010 Vital Signs:
Blood Pressure: 149/80
Pulse: 70
Temp: 97.7 F [36.5 C]
Resp. 18
Pain: 6
Ht: 70 in [177.8 cm]
Wt: 232 lb [105.5 kg]
BMI: 33.3
Gen:
Head and Neck: No scalp lesions.
Eyes: Visual fields intact, EO structures (lids, cornea, conjunctiva) without abnormality,
PERRLA, EOMI, Red reflex present
Ears: Auricles and Post-auricular regions b/l without deformity, TM intact with gray
color, mild cerum accumulation within ear canals, Weber and Rinne negative
Mouth/Teeth/Throat: Lips, gums, tongue, teeth, floor of mouth, base of tongue without
deformity. No oral lesions noted. No loose teeth. Good elevation of palate.
Nose: Nasal vaults clear, Nasal passages patent b/l. Nasal septum intact. No
frontal/maxillary sinus tenderness.
Neck: No gross deformity. No lymphadenopathy noted. No thyroid enlargement palpable.
Full ROM. Carotic pulses 2+, no bruits.
Back: No step-offs noted on spinous processes of thoracic and lumbar vertebrae, No
tenderness to percussion of thoracic, lumbar, sacral vertebrae or sacroiliac joints b/l. No
presacral edema.
Chest/Lungs: Thoracic expansion 3 cm symmetrically. CTAB.
Heart: Diminished heart sounds. Regular rate and rhythm. No murmurs, rubs, gallops.
Abdomen: Obese, large amound of excess skin present. Large amount of excess skin on
abdomen. Large midline elliptical incision scar, mildly TTP. Port sites healed. BS +.
Warm, soft. NT/ND. No masses palpable. Liver span 8 cm by percussion. Aorta 2 cm
estimated by palpation. Tip of liver not palpable. No splenomegaly. Femoral pulses 2+,
no bruit. No inguinal lymphadenopathy.
Extremities: 1+ pitting edema in LE b/l. Rash noted on anterior leg b/l. Large amount of
excess skin present on upper extremities. No cyanosis or clubbing.
Genitals: No gross deformity. No bulges, scars, ulcers, vesicles, abnormal pigmentation.
Circumcised. No discharge from urethral meatus. No masses palpable in testicles. No
hernias palpated.
Rectum: Good rectal tone. Stool in vault. No masses noted. Brown stool noted. No blood
present on examination. No hemorrhoids. Prostate palpated, symmetrical, firm, not
enlarged, no nodules.
Pulses: Rad Fem Pop DP PT Bruit
Rt: 2+ 2+ 2+ 2+ 2+ -
Lt: 2+ 2+ 2+ 2+ 2+ -
Neurological:
CN I-XII Intact
Motor: Full Passive and Active ROM in UE and LE b/l. Strength 5/5 UE and LE
proximal and distal b/l.
DTR: Biceps Triceps Brachioradialis Patellar Achilles
Rt: 2/2 2/2 2/2 2/2 2/2
Lt: 2/2 2/2 2/2 2/2 2/2
Sensory: Decreased sensation in b/l LE up to knees. UE b/l fully intact.
Labs:
5/21/10

Chem Profile:

T-PROT 6.7 g/dL 6.1 - 7.9

ALBUMIN 3.2 L g/dL 3.5 - 4.8
CHOL 131 mg/dL 0 - 200D
T. BILI 0.6 mg/dL .2 - 1.2
ALK PHO 75 IU/L 32 – 91
ALT 12 L IU/L 17 – 63
AST 22 IU/L 15 – 41

GLUCOSE 117 mg/dL 74 – 118

NA 139 mMol/L 136 – 144
K 4.6 mMol/L 3.6 - 5.1
CL 106 mMol/L 101 – 111
CO2 26.0 mMol/L 22 – 30
BUN 14 mg/dL 8 – 20
CREAT 1.00 mg/dL .64 - 1.27
URIC AC mg/dL 4.8 - 8.7
CA 9.0 mg/dL 8.9 - 10.3
LDH IU/L 98 – 192
CPK IU/L 49 – 397
TRIGLYC 87 mg/dL 0 – 150
GFR 79 mL/min Ref: >=60

CBC Profile:

WBC 3.6 L BILL/L 4 - 10.5

RBC 3.38 L TRIL/L 4.4 - 5.7
HGB 10.5 L gm/dl 13.5 - 17.5
HCT 31.1 L % 40 – 53
MCV 92.2 fL 80 – 100
MCH 31.1 pg 27.6 - 33.3
MCHC 33.7 g/dl 32 – 35
RDW 12.1 % 11.6 – 15
MPV 7.7 L fL 7.8 – 11
PLT 151 BILL/L 150 -
Assessment and Plan:

1. 51-year-old male s/p Gastric Bypass surgery in 9/07 with symptomatic protein-calorie
malnutrition due to an inability to tolerate diet vs Bulimia nervosa
a. Plan to bring to OR for Percutaneous Endoscopic Gastrostomy vs
Laparoscopic Gastrostomy tube Placement
b. Fentanyl topical patch, q patch top q 72 hr
c. Thiamine tab, 100 mg PO daily
d. Loperamide cap, 4 mg PO BID PRN
e. Oxycodone/Acetaminophen tab, PO q4h PRN
f. Zinc sulface cap, 220 mg PO BID
g. Psychiatry consultation
2. Dm Type II
a. Metformin tab, 1000 mg PO BID
3. Hypertension
a. Spironolactone tab, 50 mg PO daily
4. Insomnia
a. Trazodone tab, 150 mg PO qhs
5. Depressive Disorder
a. Mirtazapine tab, 15 mg PO qhs
6. Dyslipidemia
a. Currently controlled without medications
7. Diabetic Neuropathies
a. Gabapentin cap, 900 mg PO TID
8. Hypothyroidism
a. Levothyroxine tab 0.075 mg PO daily
9. Sensorineural hearing loss of Combined type
a. Hearing aids being used
10. Vitamin D Deficiency
a. Ergocalciferol Soln Liquid, 8000 U PO daily
11. Post-nasal drip
a. Loratadine tab, 10 mg PO daily PRN