Comprehensive: Nursing Home, dementia, diarrhea

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Comprehensive: Nursing Home, dementia, diarrhea


DOB: 3
-
17
-
13


March 14, 1995

ANNUAL H&P DICTATION


Completed/Dictated 3
-
9
-
95


CODE STATUS: DNR/DNI


This resident is an 81
-
year
-
old gentleman who is pleasant and
cooperative but not a good historian due t
o his dementia.


CHIEF COMPLAINT
: Resident has been having diarrhea according to
his records for the past week, since the 24
th

of February. He has been
having two to three large loose brown stools per day primarily in the
evening and at night. He has no
nausea, no vomiting, no decrease in
appetite, no abdominal pain and no fever. He has some vague
complaints of heart burn from time to time, pain in both groins and in
both legs. These complaints are very vague and he is unable to
elaborate or give any de
tails. The resident feels that his diarrhea is
due to eating too many apples. A conversation with the HST caring for
him reveals that the resident has been seen very frequently during the
past week at the fruit basket in the hall taking and eating fruit.


PAST HISTORY
:

1.

Childhood illnesses: Thinks he had the usual childhood illnesses.

2.

Adult illnesses:

1.

Diabetes type II diagnosed in 1986, treated with oral
hypoglycemics, has peripheral diabetic neuropathy.

2.

Gait disturbance. Began in 1986 after cholecystec
tomy,
multifactorial and related to peripheral neuropathy,
wheelchair bound since 1991.

3.

Hypertension. Present before admission in 1992, had
hypertensive crisis in January 1994, blood pressure rose to
220/120, presently controlled on Metoprolol.

4.

Cataracts,

bilateral extractions 1986, 1987.

5.

Dementia, probably Alzheimer’s. In January of 1994 RPR
was negative, B12 and folate levels were normal.

6.

Heart murmur, present at least since admission, grade
2/6.

7.

History of lower extremity edema due to venous
insufficie
ncy. A two
-
dimensional ECHO in January 1994
showed normal left ventricle. Lasix was discontinued and
Ted stockings were ordered.

8.

History of viral gastroenteritis. In January of 1990 was
found on the floor of his apartment suffering from severe
weaknes
s. Later presumed diagnosis was viral
gastroenteritis.

9.

Ileus or small bowel obstruction in January 1994. Had
questionable GI bleeding with emesis of dark material,
which was guaiac positive, and stools that were guaiac
positive. No cause was found excep
t possible a UTI. The
episode resolved with IV fluids, nasal gastric suctioning
and treatment for the UTI. A subsequent urine culture was
negative. In November 1994 resident had another episode
of guaiac positive emesis.

10.

Chest pain and MI January 1994.

Begun on
Metoprolol to control heart rate and also blood pressure.

11.

History of micro hematuria. Was evaluated by
Urology in April 1994 with IVP and cysto. The work
-
up
was negative.

12.

Incontinence probably secondary to diabetic
neuropathy.

13.

Nodule in rectum.

A 5mm submucosal nodule was
found posterior in the lower rectum on 10
-
18
-
94 on flex
sig.


PSYCHIATRIC ILLNESSES:

None known.

INJURIES
: None known.

OPERATIONS/HOSPITALIZATIONS
: Hospitalized in1986 for a
ruptured gall bladder.


CURRENT HEALTH STATUS
:

1.

Aller
gies: No known allergies.

2.

Immunizations: 10
-
21
-
94 flu, no record of pneumovax or
tetanus vaccine.

3.

Environmental Hazards: Falls.

4.

Safety Measures: Side rails on bed, use of Sara lift.

5.

Screening: Mantoux 4
-
25
-
94 was negative; no record of dental
visit or audi
ology screening, last vision screening was in 1992.

6.

Leisure activities: Likes to watch TV in room or sit out in hall,
refuses to go on outings.

7.

Exercise: Goes to physical therapy 3
-
5 times per week to walk
on the parallel bars.

8.

Sleep: States he sleeps well
.

9.

Diet: Liberal ADA.

10.


Tobacco: None.

11.

Alcohol: History of abuse from charts.


CURRENT MEDICATIONS
:

1.

Nitroglycerin patch 5mg per 24 hours, apply 8 am, remove 6
pm.

2.

Glyburide 2.5mg daily

3.

Acetaminophen 5 grains 2 tabs hs daily and 1 or 2 q 4 hours prn

4.

Cimetidin
e 400mg bid

5.

Metoprolol 50mg 1 bid

6.

ASA 80mg 1 tablet daily


PSYCHOSOCIAL
:

Resident has an eighth
-
grade education. He was born inNew Jersey.
He is Catholic. At a young age he was taken to an orphanage by his
father who never returned. He has no siblings
and no known relatives.
He has never married and has no children. He lived alone all of his
life. He served in World War II. He did farm work and worked at a
Meat Packing factory. He had a good friend who was quite close to
him and looked after him th
e later years of his life. Resident has a
positive outlook on life.


REVIEW OF SYSTEMS
: A review of systems was attempted but not
completed because the resident was unable to concentrate and his
answers were not reliable.


PHYSICAL EXAM
: Height 5’6”. Wei
ght 221 pounds. Weight 1 year
ago 205 pounds. Blood pressure 130/70. Pulse 78.

Skin
: Warm and dry, no rashes, bruises or suspicious lesions,
numerous seborrheic keratoses over the back, neck and head.

Head
: Hair thinning, scalp and skull normal.

Eyes
: V
ision good in right eye but very poor in left eye; has corrective
lenses but does not wear them. Unable to test EOMs or fields because
resident does not cooperate. Red reflex seen in both eyes and vessels
appear normal. Discs not visualized. PERRLA, co
njunctiva pink, sclera
clear.

Ears
: Drums obscured by wax bilaterally, acuity good to whispered
voice.

Nose
: Mucosa pink, no sinus tenderness.

Mouth
: Mucosa pink, poor dentition, tongue midline, no lesions on
tongue or under tongue or on buccal surfaces, p
harynx pink.

Neck
: trachea midline, thyroid not palpable.

Lymph nodes
: No palpable lymph nodes in neck, axillary, epitrochlear
or inguinal areas.

Thorax and lungs
: Thorax symmetrical, good expansion, lung fields
resonant, vesicular breath sounds throughout
, no adventitious sounds.

Cardiac
: S1 S2 normal, no S3 or S4, systolic murmur heard at apex
and left sternal border, no heaves, lifts or thrills.

Breasts
: No nipple discharge or lumps.

Peripheral Vascular
: Carotid, brachial, radial and femoral pulses stron
g
and regular. Pedal pulses very faint. Mild lower leg edema, no bruits,
normal JVP. Extremities warm, no pallor or cyanosis, no varicosities or
calf tenderness. Homan’s negative.

Abdomen
: Obese and symmetrical, large well
-
healed midline scar,
bowel so
unds normal, no masses or tenderness, no
hepatosplenomegaly, no CVA tenderness.

Genitalia
: No lesions or discharge on penis. Skin on scrotum and on
perineal area reddened and tender. Most likely irritated from diarrhea.
No testicular masses felt, althou
gh exam was limited because of
tenderness of the skin of the scrotum. No inguinal hernia.

Rectum
: No hemorrhoids, no masses, stool brown, prostate is smooth,
firm, no nodules, no unusual tenderness.

Musculoskeletal
: Range of motion normal, no joint deform
ities. Can
wheel self in wheelchair. Transfers with Sara lift.

Neurologic
: Cranial nerves 2
-
12 intact. Oriented to person and place.
DTRs are equal, motor testing intact 5/5. Diminished sensation in
stocking area of both feet. Finger
-
to
-
nose cerebell
ar testing slightly
dysmetric with left hand. Babinski toes down
-
going. Mini
-
mental


16/30.

Psychiatric
: Unable to do Geriatric Depression Scale as resident is
unable to comprehend and concentrate.


REHAB POTENTIAL: Fair.

DISCHARGE POTENTIAL: Poor.