[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 .
CHIEF COMPLAINT

Follow up adult hydrocephalus, 3 months status post shunt surgery.

HISTORY OF PRESENT ILLNESS

Mr. Christopher Watson is an 86-year-old male who returns in follow up of adult hydrocephalus. This is his first visit since undergoing shunt surgery 08/01/2020. He is accompanied by his daughter, Theresa, together they give his history.

I have followed Mr. Watson since May 2020. He presented with 8-10 years of progressive gait impairment, cognitive impairment, and decreased bladder control. We established a diagnosis of adult hydrocephalus with the spinal catheter protocol in June 2020 and he underwent shunt surgery on 08/01/2020. A Medtronic Strata programmable shunt in the ventriculoperitoneal configuration programmed at level 2.0 was placed.

Mr. Watson has had no hospitalizations or other illnesses since I last saw him. With respect to his walking, his daughter states that he is now able to walk to the dining room just fine but could not before his surgery. His balance has improved though he still has some walking impairment. With respect to his bladder control, initially there was some improvement, but he has leveled off and he wears a diaper. With respect to his cognition, both Theresa and the patient say that his thinking has improved. The other daughter, Hannah summarized it best according to the two of them, she said “I feel like I can have a normal conversation with him again.” Mr. Watson has had no headaches and no pain at the shunt site or in the abdomen.

PAST HISTORY

Urinary incontinence.
Adult hydrocephalus.
Gait impairment.
Cognitive impairment.

REVIEW OF SYSTEMS

• Constitutional Symptoms: Significant for impaired ability to carry out daily functions. Negative for fever or unintentional weight loss.
• Genitourinary: 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: Negative for depression, excessive worrying, or mood swings.

VITALS

Blood pressure 124/80, heart rate is 64, respiratory rate is 18, weight 174 pounds, and pain is 0/10.

PHYSICAL EXAM

Constitutional
Mr. Watson is a pleasant and cooperative man who is able to converse easily though his daughter adds some details.

Head and Face
The shunt site was clean, dry, and intact and confirmed at a setting of 2.0.

Neurological
Mental status: Tested for recent and remote memory, attention span, concentration, and fund of knowledge. He scored 26/30 on the MMSE when tested with spelling and 25/30 when tested with calculations. Of note, he was able to get two of the three memory words with cuing and the third one with multiple choice. This was a slight improvement over his initial score of 23/30 with calculations and 24/30 with spelling and at that time he was unable to remember any memory words with cuing and only one with multiple choice.
Gait: Tested using the Tinetti assessment tool. He was tested without an assistive device and received a gait score of 6-8/12 and a balance of score of 12/16 for a total score of 18-20/28. This has slightly improved from his initial score of 15-17/28.
Cranial Nerves: Pupils are equal. Extraocular movements are intact. Face symmetric. No dysarthria.
Motor: Normal for bulk and strength.
Coordination: Slow for finger-to-nose.

RESULTS

CT scan of the head from 10/15/2020: It shows a frontal horn span at the level of foramen of Munro of 4.6 cm with a 3rd ventricular contour that is flat with the span of 10 mm. By my reading, there is a tiny amount of blood in the right frontal region with just a tiny subdural collection. This was not noticed by the radiologist who stated no extra axial fluid collections. There is also substantial small vessel ischemic change.

ASSESSMENT

• Adult hydrocephalus.
• Gait impairment.
• Urinary incontinence and urgency.
• Cognitive impairment.

Mr. Watson has made some improvement with his hydrocephalus since shunt surgery. There is a tiny fluid collection in the right parietal region. I do not believe that this tiny amount of fluid is symptomatic, and it was not documented by the radiologist when he read the CT scan.

Mr. Watson asked me about whether he will be able to drive again. Unfortunately, I think it is unlikely that his speed of movement will improve to a level that he will be able to pass a driver's safety evaluation, however, occasionally patients surprise me by improving enough over 9 to 12 months that they are able to pass such a test. I would certainly be happy to recommend such a test if I believe he is likely to pass it and he is always welcome to enroll in a driver's safety program without my recommendation, however, I think it is exceeding unlikely that he has the capability of passing this rigorous test at this time. I also think it is quite likely he will not regain sufficient speed of motion to pass such a test.

PLAN

I had a long discussion with the patient and his daughter. We are all pleased that he has started to make some improvement with his hydrocephalus because of the fluid collection in the right parietal region, I would like to leave the setting at 2.0 for another three months before we consider changing the shunt.

INSTRUCTIONS

Follow up in 3 months.