Mrs. Humphreyis a 92 year old who presents to your clinicwith her daughter who is also her caregiver. She wasrecently on Levofloxacin for a UTI about one week ago. She does not have any urinary symptoms but is concerned because she is very weak and does not have the strength to walk far distances without resting. She also states that she is feeling more “foggy” lately andis having difficulty concentrating for example sheis unable to balance her checkbook and is something she has been able to do without difficulty. She is a littlemore short of breath than usual and hasincreased edema in both feet worse at the end of the day. She reports occasional diarrhea the last week.

She was recently started on Amlodipine 5mg dailybecause her blood pressure was a little elevated about a month ago. Other than that, all of her medications are the same.

ROS:

General: Denies weight loss/gain, no fever, chills or night sweats, see HPI

HEENT: No recent cold sx, otherwise negative

Resp: No cough or wheezing, see HPI

CV: Denies CP, palpitations, orthopnea or PND

Abdomen: Denies abdominal pain, appetite is fair, see HPI

Ext: No claudication, calf pain or venous insufficiency, see HPI

Neuro: No parestheisas, no numbness or tingling

PMH:HTN, Afib, Osteoporosis, PUD, OAB

PSH: None

Allergies: None

Social: Never smoked or drank

Meds:

Coumadin 5mg daily

Amlodipine 5mg daily

Metoprolol 50mg bid

Oxybutinin 5mg daily

Calcium 600mg bid

Aspirin 81mg daily

Ranitidine 150mg bid

Omeprazole 20mg daily

Physical Exam:

VS: BP sitting 110/66 P- 100; Lying 120/84 P- 98, standing 90/48 P- 110, RR 22 HT: 5’6” Wt: 175 BMI = ……..Pulse ox: 93% RA

Lungs: Bilateral rales to lower lobes, no wheeze

Heart: Irregular– good S1 and S2. No S3 or S4, murmurs, rubs, or gallops.

Abdomen: + BS x 4 quadrants. No masses or tenderness. No hepatomegaly. No CVAT, no suprapubic tenderness

Ext: +2 PPP bilateral DP and PT,+1-2 pitting edema to bilateral lower ext

Neuro: A&Ox3,28/30 MMSE (down 2 points from last visit, unable to draw intersecting pentagons and write a sentence), Clock drawing test-all points

# MMSE above 26 is still normal but pt dropped 2 points, dropped 3 points will be concerned. Pt started to have mild impairment as she has problem managing finances , monitor and assess for sign of abuse

Labs:

UA—Negative LE and nitrates

Trace Hgb

Trace protein

Stool for OB +

No recent labs, last drawn a year ago

# Question 1: Name the top 3 differential diagnoses for this patient.

# Question 2: What, if any of her medications would you consider discontinuing or adjusting?

# Question 3: Which of the following labs/diagnostic tests would you consider ordering for this patient?

# Question 4: Given her age and symptomatology, what is the most likely cause of her foggy?

# Question 5: You have her follow up in 2 months. When administering the MMSE, you notice her score has remained the same at 24/30. What would your next course of action be?

# Question 6: Which medications might you consider prescribing given her presentation?