[doctor] okay , so our next patient is christopher watson . date of birth 04/12/1934 . mr . watson is- is an 86-year-old male who returns in follow-up for adult hydrocephalus . this is his first visit since undergoing sh- shunt surgery , excuse me , on august 1st , 2020 .
[doctor] i have followed mr . watson since may of 2020 when he first presented with eight to ten years of progressive gait impairment , cognitive impairment , and decreased bladder control . we established a diagnosis of adult hydrocephalus with a spino catheter protocol in june 2020 , and he underwent shunt surgery on august 1st , 2020 . a medtronic strata programmable shunt in the ventricular peritoneal configuration was programmed at a level 2.0 was placed .
[doctor] good morning , mr . watson , who is the nice lady you have with you today ?
[patient] hi , doc . this is my daughter , theresa . she is the one who helps me keep things straight .
[doctor] mr . watson , have you been sick or been hosp -- hospitalized since your shu- shunt surgery three months ago .
[patient] uh , not that i recall .
[patient_guest] no , he has n't . he has been doing much better .
[doctor] good , i'm glad to hear that .
[doctor] before surgery , you were having some progressive problems that affected your walking , thinking , and bladder control . are these symptoms better , worse , or unchanged ?
[patient_guest] his walking has improved . he's now able to walk to the dining room just fine . but he could not do that before surgery . he still has times where i have to help him .
[doctor] that's impressive , mr . watson .
[patient] yeah , i guess .
[patient_guest] now his bladder control did improve some after surgery , but now seems to have leveled out . so he is wearing diapers .
[doctor] no issues with sores from wearing the diaper ? and any decreased or painful urination ?
[patient_guest] no , not at all .
[doctor] and how about cognition ?
[patient] i think i'm better . i do n't feel lost when talking to someone anymore .
[patient_guest] dad and i both think my sister , hannah , summarized it best . she said " i feel like i can have a normal conversation with him again , "
[doctor] that's so wonderful ! now have you had any headaches or pain where the shunt is ?
[patient] no . has n't bothered me one bit .
[doctor] okay . and any pain in your belly at all ?
[patient] ca n't say that i have .
[doctor] okay , sounds like you have been improving . alrighty , mr . watson , i'm going to step out of the room while my resident comes in to do a few tests for me . is that all right ?
[patient] sounds good .
[doctor] okay , i'm going to go out and review the ct scan you had last month , and then we'll chat about it when i come in .
[doctor] all righty , mr . watson , so you definitely have made some improvements since the shunt surgery . now on ct scan though i do believe i see a tiny bit of blood fluid collection in the right parietal region . now , i do n't believe that that's causing any symptoms , and i , it actually was n't documented by the radiologist when he read the ct scan .
[patient] so what does that mean ?
[doctor] just that i would like to leave the shunt set for another two to three months before we go in changing it . like i said , if you're not having any headaches or pain and you have improved so that's all good for me . so really there's , there's nothing to worry about .
[patient] all right so i'll come back in three months ?
[doctor] yep , that's right .
[patient] i do have a question for you though .
[doctor] yeah , of course .
[patient] do you think i will be able to drive again ?
[doctor] ah man , mr . watson , i knew you were gon na ask me that one . i think at this point it's unlikely that your movement speed will improve to the level that would be needed for you to pass the driver safety evaluation . now , i will say that i do occasionally have patients who surprise me by improving over a nine to 12 month range . and that , that definitely could be you . you could definitely pass it at that point . so if you improve and we can continue to talk about that then , ya know , i think it could be possible , um , and i'd be happy to recommend it .
[doctor] now , you could definitely also enroll in a driver safety program without my recommendation . so you could kind of do that preemptively , and then we could continue to watch for your improvement as we go .
[patient] okay . i kinda figured that anyway but i just thought i'd ask . i do n't like to burden anyone when i just need to run to the store but i also know that i need to be safe .
[doctor] yeah , your safety is our number one priority and , ya know , i'm sure your daughters do n't mind as much , right , they want to keep you here and have you safe . but , i overall am very pleased with how much you have improved . and so , i'm sure when we talk again in three months , we'll continue to be on that upward trajectory or improvement .
[patient] i sure hope so , doc .
[patient_guest] we really appreciate all that you've done . do we make the appointment out front ?
[doctor] yeah , that would be great . the girls up front will take care of you and get you settled for three months from now , and you both take care , all right ?
[patient] thanks
[patient_guest] thank you .
[doctor] all righty , so ros is constitutional significant for impaired ability to carry out daily functions . negative for fever or unintentional weight loss . gu is significant for urinary incontinence and wearing a diaper . negative for genital sores , decreased or painful output . neurological significant for continued walking impairment and cognitive impairment . negative for headaches , recent falls , or hallucinations . psychiatric is negative for depression , excessive worrying , or mood swings .
[doctor] let's go ahead and use the short pe . vitals , let's see , blood pressure is 124/80 , heart rate 64 , respirations 18 , weight 174 pounds , and pain zero out of 10 .
[doctor] mr . watson is a pleasant and cooperative man who's able to converse easily through , um , though his daughter does add some details . the shunt sight was clean , dry , and intact with a confirmed setting of two . um he was tested um for recent and remote memory , attention span , and concentration in fund of knowledge . he scored a 26 out of 30 on the mmse when tested with spelling and 25 out of 30 when tested with calculations . of note , he was able to get two of the three memory words with cuing , and the third with multiple choice . this was a slight improvement over his initial score of 23 out of 30 with calculations and 24 out of 30 with spelling . and at the time he was unable um in the previous test , excuse me , he was unable to remember any memory words with cuing without and only one with multiple choice .
[doctor] gait testing using the tinetti assessment tool . he was tested without an assistive device and received a gait score of six to eight out of 12 and a balance score of 12 out of 16 for a total score of 18 to 20 out of 28 . this is slightly improved from his initial score of 15 to 17 out of 28 .
[doctor] cranial nerves , pupils are equal . eoms are intact . face symmetric . no disarchria . motor normal for bulk and strength . coordination slow from no- finger to nose . of note , the ct scan from the head of 10/15/2020 shows a frontal horn span at the level of foramen of monro of 4.6 centimeters with a third ventricular contour that is flat with a span of 10 millimeters . by my reading there is a tiny amount of blood in the right front region with a tiny subdermal collection . this was not noticed or noted by the radiologist who stated any extra axial fluid collections . there is also substantial small vessel ischemic change .
[doctor] diagnosis adult hydrocephalus , gait impairment , urinary incontinence and urgency , and cognitive impairment .

Medical orders:
description: come back three months
order_type: followup
reason: adult hydrocephalus