LTC

H&P

 

June 8, 2018

Time: 10 am

 

 

Identification: Miss A.

 

Informant: patient; reliable

 

 

CC: “Progressive weakness” x1 year

 

 

HPI:

84 y/o female with PMHx of HTN,  Inclusion body myositis  was admitted to NYPQ s/p fall at her home. Diagnostic workup was negative for fractures. As per patient, she has been progressively getting weaker over the past year with onset of dysphagia. The patients states that her weakness started from her distal lower extremities and gradually progressed to her proximal lower extremities. She was started on MTX November 2017 with noted improvement in her sxs. However, she is not able to ambulate  and requires assistance in her ADLs. She denies upper extremity weakness, stiffness, shortness of breath, chest pain, dizziness, paresthesia, slurred speech. Patient transferred to Margaret Tietz  per her request for further rehabilitation and care.

 

PMHx:

Inclusion body myositis ( since 2007)

HTN

Constipation

 

PSHx: None

 

Allergies:

NKDA

 

Medications:

Losartan Potassium Tablet 50 MG 1 tablet by mouth one time a day

Methotrexate Tablet 2.5 MG  6 tablet by mouth in the evening every Wed

Docusate Sodium Capsule 100 MG capsule by mouth at bedtime

 

 

 

Family Hx :

Unknown

 

 

 

Social Hx:

Lives alone in an appt with elevator access.

Holocaust survivor

Retired History professor

Denies tobacco, drug, alcohol use, caffeine, recent travel

Healthy diet

 

 

ROS:

General

Positive for generalized weakness, fatigue.  Denies recent weight loss and night sweats,  loss of appetite, fever, chills.

Skin, Hair, Nails:

denies pruritus, changes in hair distribution, diaphoresis

Head:

denies HA, vertigo, head trauma, unconsciousness.

Eyes:

Uses reading glasses. Denies diplopia, fatigue with the use of eyes, scotoma, halos, lacrimation, photophobia, pruritus

Ears:

denies deafness, pain, discharge, tinnitus

Nose/sinuses:

denies discharge, epistaxis, obstruction

Mouth/Throat:

denies bleeding, sore throat, oral lesions

Neck:

denies localized swelling, positive for stiffness and decreased range of motion

Cardiorespiratory System:

Denies CP,  palpitations, DOE, dyspnea, orthopnea, paroxysmal nocturnal dyspnea, edema, cough, hemoptysis, syncope, wheezing, no known murmurs

GI system:

Positive for dysphasia. Denies nausea and vomiting, abd. pain, decreased appetite, Denies intolerance to specific foods, diarrhea, jaundice, changes in bowel habits, hemorrhoids, constipation.

Genitourinary System:

denies hematuria, proteinuria, nocturia, increased urgency, oliguria, polyuria, dysuria, incontinence, pain. Denies any vaginal discharge.

Nervous System:

Denies seizures, sensory disturbances,  loss of strength, positive for loss of strength in b/l lower extremities and ataxia, changes in cognition, mental status, memory forgetfulness.

Musculoskeletal System:

Positive for bilateral lower extremities muscle weakness and decreased ROM. Has mild muscle pain in UE and LE. Denies intermittent claudication, coldness, trophic changes, varicose veins, peripheral edema, any skin changes.

Hematologic System:

Denies anemia, easy bruising, lymph node enlargement

Endocrine System:

No history of diabetes, Denies polyuria, polydipsia, polyphagia, heat or cold intolerance, goiter

Psychiatric:

Denies depression, sadness, feeling of hopelessness, helplessness, lack of interest in usual activities, suicidal ideations, anxiety, obsessive compulsive disorder, and psychiatric medication

 

Physical Exam:

General:

Patient is A&Ox3,  build with good posture, no acute distress, appears younger than her stated age.

 

Height: 5’6

Weight: 173.5

BMI: 28.0

 

Vitals:

Temp: 98

RR: 17, unlaboured

HR: 17 Regular

BP:  134/85 sitting right arm

O2 sat:  98

 

Skin: Normal color, good turgor. Warm and moist. No evidence of any rash

Nails: no clubbing, lesions or infections noted; capillary refill <2 sec throughout

Hair: normal hair distribution

Head: normocephalic, atraumatic, no scars or lesions, specific facies, non tender to palpation through out

Eyes: no dryness, signs of infection noted on eyelashes, eyebrows or eyelids, lacrimation glands or lacrimation sacs. Sclera is white, normal position. EOM’s full with no signs of nystagmus, red reflex intact. PERRLA.

Ears: symmetrical, normal shape, color and size, no lesions; pinna non-tender to palpation bilaterally

Nose: Symmetrical, no masses, lesions, deformities, trauma discharge. Septum midline without lesions, deformities.

Mouth/Oropharynx

Lips: are pink, moist, no evidence of cyanosis or lesions, non-tender to palpation

Mucosa: is pink and well hydrated, palate intact with no lesions, masses, scars; non tender to palpation and continuity intact.

Teeth: good dentition

Gingivae: pink, moist, no evidence of hyperplasia, masses, tensions, erythema, discharge, non tender to palpation

Tongue: pink, well hydrated and papillated , no masses or lesions, dentitions: non tender to palpations

Oropharynx: well hydrated, no evidence of exudates, masses, lesions, foreign bodies; tonsils are present with no evidence of injection or exudate. Uvula is pink, midline, no edema, no lesions

Neck: Trachea midline, no masses, lesions, scars, pulsation noted

2+ carotid pulses; no thrills, bruits, no palpable adenopathy noted, full range of motion

Thyroid: non tender to palpation, no palpable masses, no thyromegaly, no bruits noted

Chest: symmetrical, no deformities, no evidence of trauma; respiration unlabored, no paradoxic respiration or use of accessory muscle. Lat to AP ration: 2;1 non tender to palpation

Lungs: clear to auscultation bilaterally. No adventitious sounds such as wheezing, crackles, rales and rhonchi

Heart: RRR, S1 and S2 are normal, no murmurs, no extra heart sounds such as S3 and S4. No rubs, gallops, clicks.

Abdomen: Flat symmetrical, no evidence of scars and incisions. No evidence of caput medusa or abnormal pulsations. Bowel sounds in all 4 quadrants; no bruits noted over aortic, renal, iliac, femoral arteries. Non tender to palpation. No evidence of organomegaly; no masses noted, no evidence of guarding or rebound tenderness; no CVAT noted bilaterally

Rectal and Genital Exam: not performed

Peripheral vascular and extremities: Skin is normal color and warm to touch in UE and LE. No calf tenderness, edema, cyanosis, varicose veins bilaterally.

Musculoskeletal: Normal ROM in Upper Extremities. No active range of motion in b/l lower extremities. No joint swelling or tenderness noted. Unable to ambulate, unstable gait.

Neuro Exam: A&Ox3, CN 2-12 grossly intact. Normal strength in UE. ⅕ strength in b/l lower extremities.  Sensation and DTRs intact.

 

 

 

Plan/Assessment: 84 y/o female with PMHx of Inclusion body myositis (2007)was admitted to NYPQ s/p fall at her home. Diagnostic workup was negative for fractures. Pt  has been progressively getting weaker over the past year with onset of dysphagia.  Pt is not able to ambulate  and requires assistance in her ADLs. On PE pt has no active ROM and decreased strength ⅕ in lower extremities. She denies upper extremity weakness, stiffness, shortness of breath, chest pain, dizziness, paresthesia, slurred speech. Patient transferred to Margaret Tietz  per her request for further rehabilitation and care.

 

 

HTN

Losartan Potassium Tablet 50 MG

Give 1 tablet by mouth one time a day

Monitor BP

 

Inclusion Body Myositis

Methotrexate Tablet 2.5 MG (Methotrexate Sodium)

Give 6 tablet by mouth in the evening every Wed

 

 

Constipation

Docusate Sodium Capsule 100 MG

Give 2 capsule by mouth at bedtime

Advised prunes to diet

Monitor bms

 

Gen weakness/Unsteady gait

B/L Lext weakness

PT/OT/Physiatry consults and treats as tolerated.

 

Dysphagia

Speech pathology consult

 

Pain management

Acetaminophen Tab 500 mg PO PRN Q4h

 

 

Primary DDx: Inclusion body myositis

 

DDx:

1. Polymyositis – IBM and polymyositis can in some cases be difficult to distinguish clinically or by muscle biopsy. In the absence of rimmed vacuoles or protein aggregates found on immunostaining or electron microscopy, the muscle biopsy in IBM may only demonstrate endomysial inflammation that closely resembles that seen in polymyositis. Combining clinical and histologic findings increases the chance of a correct diagnosis. The lack of response to high-dose steroids should lead to a reevaluation of the diagnosis of polymyositis, which is increasingly recognized as a rare entity. Pattern of weakness:proximal with muscle pain and inflammation.
2. Heritable myopathies

• Hereditary inclusion body myositis (hIBM) – These patients present with slowly progressive muscle weakness (variously labeled familial distal myopathy, autosomal recessive hereditary inclusion body myopathies, and distal myopathy with rimmed vacuole formation), usually with marked distal muscle group involvement, and the muscle biopsy shows a vacuolar myopathy with inclusions. In contrast to sporadic IBM, the onset of weakness is usually in early adulthood and spares quadriceps muscles. The family history and a paucity of inflammation on histologic examination help to distinguish these rare heritable disorders from sporadic IBM.
• Muscular dystrophy – Other inherited myopathies that variably show rimmed vacuoles and/or inflammation of muscle biopsy can occasionally be misdiagnosed as IBM. The correct diagnosis can usually be suspected based on the earlier age of onset, the pattern of weakness, and/or family history. Diagnosis is confirmed by genetic testing.

3. Drug-induced myopathies – Vacuolar changes are also present in drug-induced myopathy due to colchicine and chloroquine. The more acute presentation and drug history differentiate these conditions from IBM.
4. Amyotrophic lateral sclerosis – Patients with IBM who have predominantly distal or asymmetric involvement may resemble motor neuron disease or peripheral neuropathies with predominantly lower motor neuron involvement. Electrophysiologic testing and muscle biopsy may be necessary to establish the correct diagnosis. Electromyography (EMG) of the forearm flexor muscles may be particularly useful in distinguishing the primarily myopathic features of IBM from the neurogenic features of ALS.