Comprehensive: Nursing Home, shoulder pain, back
and hip pain, pain in lower legs and feet, fullness in
ears
Background Information: This 91 year old white female was
transferred to this long-term care facility from another nursing home
three days ago. She is alert and oriented and is a fairly good
historian, but is somewhat vague and tends to ramble when describing
present complaints and symptoms. Additional information was
obtained from a discharge summary from her July hospitalization and
some information was obtained from her daughter.
Chief Complaints
1. Pain and limited range of motion in R shoulder for 8 or 9 years.
States has both sharp and aching pain in R shoulder when using
arm. Onset was gradual, not related to fall. Pain occurs when
she uses arm, especially when using walker to walk in physical
therapy or when trying to raise arm over head. She is unable to
raise arm over her head or comb her hair. Pain does not
interfere with sleep. Had a similar problem with the left
shoulder, but that has spontaneously resolved. Pain is not
significantly helped by acetaminophen or ibuprofen. States she
had an x-ray several years ago, which showed calcium deposits,
but her orthopedic surgeon told her that nothing could be done
about it. Chart indicates a rotator cuff problem and
osteoarthritis. Pain in the shoulder interferes with ability to
exercise and walk in physical therapy. Both resident and
daughter are in favor of physical therapy, but in light of her age
they do not wish for the therapists to “push” her beyond what
she feels she can comfortable do.
2. Pain in lower back and hips. Pain is aching and occurs while
resting but especially when walking. Has been present for a
number of years. Does not radiate down legs. Does not
interfere with sleep. States pain is helped by Aspercreme which
she uses several times a day and aspirin, but she does not take
aspirin because of her kidneys.
3. Pain in lower legs and feet. Pain is both burning and aching and
sometimes cramping and has been present for at least several
years. Pain is worse in the early morning hours. States she
takes quinine at H.S. for the cramps and believes it helps some.
Getting out of bed also brings some relief, as do acetaminophen
or ibuprofen. Chart indicates a previous diagnosis of peripheral
neuropathy.
4. Discomfort, fullness in ears. Hearing aid has been singing lately.
Prior history of cerumen build-up in ears requiring frequent
removal.
Past History
1. General Health: Fair. Health has deteriorated since CVA in July.
Rehab potential has been listed as poor.
2. Childhood Illnesses: Thinks she had measles, mumps, and
chicken pox.
3. Adult Illnesses:
a. CVA involving R basal ganglion in July, 1995.
b. Type 2 IDDM of longstanding duration. Glycosolated
hemoglobin from 6 months ago was 9.5, creatinine was
1.4, BUN 30. Accuchecks of last few days 118-141 before
breakfast and 168-315 before dinner.
c. Bladder incontinence. States has had difficulty controlling
urine for several years now. Some dribbling, stress
incontinence. Wears a pad.
d. Osteoarthritis. Generalized. Bilateral total knee
arthroplasty Shoulder, L elbow, back, and hip pain,
osteoarthritic changes in fingers.
e. Skin cancer of nose. Surgically removed 2 years ago.
f. Carpal tunnel syndrome of both wrists many years ago.
g. Hiatal hernia present for a number of years.
h. Ventral hernia – complication of abdominal surgery in
distant past.
i. History of congestive heart failure – per chart – no details
available. Recent chest x-ray showed cardiomegaly.
j. Chronic bronchitis – diagnosed 1½ years ago.
k. Osteoporosis of longstanding duration.
l. History of gout.
m. Diabetic gastroparesis.
4. Psychiatric Illnesses: None.
5. Accidents and Injuries: None.
6. Operations/Hospitalizations:
a. Appendectomy – 1930.
b. Hysterectomy for cervical cancer – 1947.
c. Cholecystectomy – 1957.
d. A/P repair – 1965.
e. R 2nd toe amputation for osteomyelitis – 1993.
f. R and L total knee arthroplasty – 1990.
g. R cataract extraction several years ago.
Current Health Status
1. Allergies: None.
2. Immunizations: Flu shot last fall. Does not know about
Pneumovac or tetanus booster, neither does daughter.
3. Environmental Hazards: Needs assistance transferring, potential
for falls if attempted alone.
4. Use of safety measures: Half-length side rails on bed to prevent
rolling out or forgetting to call for assistance to get up.
5. Exercise and Leisure Activities: Receiving physical therapy. Used
to enjoy crafts and participating in groups. Plans to pursue
these activities in this facility with assistance from recreational
therapy.
6. Screening Tests: First step of two-step Mantoux negative.
Audiology – has been fitted for hearing aid. Not using now until
wax removed from ears. Vision – saw eye doctor last spring.
Dental – has upper and lower dentures. Had mouth exam and
dentures checked last September. Cannot recall last
mammogram or pap smear.
7. Diet: Diabetic Diet with thickened liquids. Usually eats 100% of
food.
8. Tobacco: No.
9. Alcohol: No.
10.
Sleep: States she sleeps well at night.
11.
Current Medications:
a. Lente Insulin 27 U, Regular Insulin 11 U q. a.m.
b. Lente Insulin 10 U, Regular Insulin 4 U before dinner.
c. Propulsid 10 mg q 6 h
d. Cimetidine 400 mg bid
e. ASA 81 mg qd
f. Lasix 20 mg qd
g. Vit C 500 mg qd
h. CaCarbonate 500 mg Vit D 125 U qd
i. Quinine 260 mg q HS
j. Synthroid 25 mcg qd
k. Acetaminophen 325 mg iqd and 1-2 tid prn
l. Ibuprofen 200 mg 1-2 tid prn
m. Aspercreme to joints bid
n. Hypotears prn
Psychosocial
Was married to first husband for 20 years, lived on a farm, and had 7
children. Marriage ended in divorce. Was trained and worked as a
psychiatric technician. Her second husband died of a heart attack
after only 13 months of marriage. Third husband is also deceased.
She is Methodist and has a strong faith. She has always like people
and used to enjoy going to community dances. She had a close
relationship with three of her children who live in the area, especially
with her daughter. She was in a nursing home 6 months but moved
here to be closer to her children.
Review of Systems
1. Skin: Denies skin problems such as suspicious nevi, pruritis,
rashes. No nail changes.
2. Head: Denies unusually frequent or severe headaches. No
dizziness, syncope, vertigo.
3. Eyes: Has corrective lenses and can read with glasses. No pain,
discharge, or lesions, but does complain of tearing of eyes,
especially when trying to read. Has implant in R eye postcataract surgery.
4. Ears: Denies tinnitus, earache, or discharge. c% fullness – wax
in ears – a frequent problem. Uses hearing aid.
5. Nose and Sinuses: Denies epistaxis, frequent colds, pain,
allergies, or nasal obstruction.
6. Mouth and Throat: No pain, bleeding gums, lesions, hoarseness,
sore throat, dysphagia, or toothache.
7. Neck: Denies pain, lumps, or swollen glands. c% intermittent
arthritic neck pain.
8. Respiratory: Has dry cough which she states mostly occurs while
eating. Wheezing and some shortness of breath on exertion
related to chronic bronchitis.
9. Breasts: No pain, lumps, or nipple discharge.
10.
Cardiac: Denies chest pain, palpitations, or
lightheadedness. No PND, orthopnea. Has chronic edema of
lower legs.
11.
Gastrointestinal: Appetite good, but would like to have diet
changed as she does not like thickened liquids. No indigestion,
abdominal pain, nausea, vomiting, constipation, or diarrhea.
12.
Genitourinary: No dysuria, frequency, or urgency. Some
incontinence of urine. No vaginal bleeding, discharge, or itching.
13.
Peripheral Vascular: No pallor, cyanosis, varicose veins or
ulcers.
14.
Neurologic: Burning pain in lower legs and feet as above.
Denies seizures, tremors, or paralysis. Denies swallowing
problems. Admits to some memory problems.
15.
Musculoskeletal: Generalized arthritic joint pain, limited
movement of R shoulder. Unable to transfer or walk alone. Can
propel self in wheelchair short distances.
16.
Hematologic: Denies easy bruising or bleeding.
17.
Endocrine: Denies unusual hunger, thirst, or urination. No
heat or cold intolerance.
18.
Psychiatric: Denies anxiety or depression.
Physical Exam
HT 5 ft. 7 in.
WT 209 lbs.
BP 134/80 P 80
Skin: Warm and dry. No rashes, suspicious lesions, or bruises.
Venous stasis changes over lower legs.
Head: Hair of average texture. Scalp normal.
Eyes: Conjunctiva pink. Sclera clear. Pupils equal and reacting to
light. EOMs intact, no nystagmus. Visual fields appear to be full.
Fundoscopic exam – red reflex seen, unable to visualize discs.
Ears: Wax obscures both tympanic membranes. Has diminished
hearing bilaterally.
Nose: Mucosa pink, no sinus tenderness.
Mouth: Mucosa pink. Upper and lower dentures appear to fit well. No
lesions on tongue or floor of mouth. Pharynx pink.
Neck: Some limitation of movement. Trachea midline. Thyroid not
palpable.
Lymph nodes: No palpable lymph nodes in neck, axillary, epitrochlear,
or inguinal areas.
Thorax and Lungs: Lung expansion good, fields resonant. Vesicular
breath sounds throughout. No adventitious sounds.
Breasts: No masses, no nipple discharge, no skin changes.
Cardiac: No heaves, lifts, or thrills. S1 S2 normal. No S3 S4 or
murmur. Regular rhythm.
Peripheral Vascular: No JVD. Carotid, radial, and femoral pulses
present and equal. Pedal pulses not palpable, but capillary refill in
toes is good and feet are warm. No bruits. No varicosities or calf
tenderness. 1+ lower extremity edema bilaterally.
Abdomen: Obese, symmetrical. Soft, no masses, no tenderness.
Bowel sounds normal. No hepatosplenomegaly. No CVA tenderness.
Genitalia: No external lesions. Declined vaginal exam and pap smear.
Rectum: No masses, stool brown.
Musculoskeletal: Limited range of motion of L elbow and R shoulder.
Muscle strength in extremities equal bilaterally.
Neurologic: Alert, oriented to person, place, and time. Only one
question wrong on abbreviated Mini-Mental exam. Cranial nerves IIXII grossly intact. Cerebellar function normal. Sensation in upper and
lower extremities intact bilaterally. Toes down-going. Unable to do
Romberg.
Psychiatric: Mood and affect do not indicate depression or anxiety.