Comprehensive: Extended care, cellulitis upper arm,
weakness, fatigue, lower extremity edema
Identifying Data: 87 yo Caucasian male, retired grain mill worker
from North Dakota. DOB 5/21/07.
Chief Complaint: Admitted to ECF to continue recovering from
cellulites in L upper extrem. He voices concern about being weak and
tired, and swelling in lower extremities.
1. Weakness and fatigue: Pt. feels these symptoms started
together and are related. Since cellulites, has not felt as strong
as he had before, and feels he tires easily. Activities wear him
out and he needs to sit down and take a rest during the process.
Is unsteady up on his feet, but feels his balance is good. Sitting
down for short rest relieves his fatigue, and he feels stronger
when he gets up. Says he naps more often during the day, no
change in his sleep habits at night.
2. Swelling in lower extremities: Began to have edema in feet and
ankles last fall, controlled with Lasix, elevation, and knee high
TED hose. Since hospitalization, the edema has increased, he
feels his legs are swollen up to the thighs, and at times his penis
and scrotum are also swollen. Pt. unable to explain increased
edema. Sitting in a recliner results in less edema than sitting
with feet dependent. Swelling in penis and scrotum is less than
2 days ago. Continues to take Lasix daily. Feels the edema may
be part of his weakness and unsteady feeling when up.
Past History
General State of Health: Felt general state of health to be good until
CLL diagnosed last fall. Had regained strength after chemotherapy.
Childhood Illnesses: Measles, mumps, and chicken pox.
Adult Illnesses and Surgeries:
1. Cellulitis R hand and forearm 5/95, Staphylococcus aureus and
Klebsiella, resolving treatment with IV antibiotics, whirlpool,
topical antibiotics.
2. CLL diagnosed 11/94. Treated with Fludarbine.
3. Angina.
4. Syncope secondary to trauma to R side of head in 1943.
5. BPH with TURP about 15 yrs ago
6. Cholecystectomy 10 yrs ago.
7. Staph impetigo 3/95.
8. Hx colon polyps, unable to recall date.
9. Hx chronic bronchitis, states asymptomatic for years.
Psychiatric History: None.
Current Health Status
Immunizations: NKDA, Pneumovax in 1993, Tetanus booster 1993,
last flu shot was in fall 1993.
Screening: Has yearly physical exam. Dentures are 4 yrs old. Last eye
exam 3 yrs ago.
Safety Measures: No longer drives automobile, uses seatbelt. Has
chair in tub, would like to get grab bars in bathroom. Has smoke
detectors in home.
Leisure/Exercise: Has not gotten any regular exercise since last fall,
has daily visitor of retired nurse friend. Likes to read and watch TV.
Sleep: Sleeps from 21:30 – 08:00, waking 3-7x nightly to void. Feels
rested in a.m.
Tobacco: Smoked in 1943 for a few months, no tobacco use since.
Alcohol/Drugs: No alcohol use for past 2 years, previously only drank
when out dancing. Denies illicit drug use.
Current Medications:
1. Lasix 40mg daily
2. KCI 20 meq daily
3. Senokot 1 q am
4. Cephedrine 250mg qid
5. Acyclovir 400mg tid
6. Magic Mouthwash qid and prn
7. ASA 325mg daily (on hold)
8. Nitro .4mg sl prn CP
9. 1% Silvadene to L hand and arm, groin
Diet: Regular diet. Does not care for the taste of salt, so avoids.
Family History: Mother died in her late 80s of cancer of the throat.
Father died at age 84 of prostate problems. 6 brothers and 3 sisters,
all living and healthy. Has 1 son, healthy, Chem Dep Tx x 1, presently
not using. No family history of heart disease or diabetes.
Psychosocial: Wife died in 1966. Lives alone in 1½ story home in
Superior. Kitchen, bedroom, and bathroom all on main floor. Only
son lives in Hawaii, talk weekly on phone. Has retired nurse friend and
her family who assist him with ADLs and IADLs. Nurse friend has
Power of Attorney for him. Hopes to be strong enough to return
home, but is considering selling home and moving into an apartment
or NH.
Religion: Lutheran, has not been back to church since wife died.
Outlook: Feels he has lived a good life, wants full resuscitation
measures taken.
Abuse: States no one has, or is hurting him.
Review of Systems
General: Feels “poorly,” weak, and tires easily.
Skin: Noticed pain, redness, warmth and swelling in L hand and arm
5/14/95. Treated with IV antibiotics, presently has minimal discomfort
in the area. Two days ago noticed itching in groin and scrotal area,
Dr. has been treating with Silvadene cream. Denies any other open
areas or rashes.
Head: Denies Has, LOC.
Eyes: Vision good with glasses, no crusting or itching. Denies diplopia.
Ears: No hearing in R ear since trauma in 1943. Denies ear pain or
tinnitus. Feels he is slightly HOH in L ear.
Nose: Reports good sense of smell. No rhinorrhea, no epistaxis.
Mouth/Throat: Has lesions on tongue and lips. Developed 4 days ago.
Denies pain when talking or resting, does have discomfort when eats
very hot or rough textured foods. Soft foods and liquids of any
temperatures seem to sooth sores. Has scratchy throat, more
noticeable when swallowing. Denies dysphagia, does not feel airway is
compromised.
Neck: Denies pain or lumps.
Respiratory: Denies cough, hemoptysis, or dyspnes. Sleeps with HOB
flat.
Cardiac: Has episodes of “chest pressure” once/week. Pressure does
not radiate, no dyspnea, no diaphoresis. Feels these episodes occur
with “excitement,” when there is a lot of activity going on in his home.
Episodes do not seem to relate to eating, with activity, or wake him at
night. Resolve quickly with sl Nitro.
GI: Feels abdomen is bloated, feels more bloated after meals. Since
hospitalization has had 2-3 soft formed stools each day. Passes more
flatus than at home. Urgency when he feels the need to move bowels,
did have episodes of incontinence last week when the nurses were
unable to answer his light in time. No incontinence past 2 days.
Bloating is relieved after passing stool or flatus. No nausea, emesis,
or belching. Before hospitalization, had good appetite, no indigestion,
ate prunes, and had soft formed stool daily.
Urinary: Has urgency when he takes Lasix. Voids 7-8 times after
taking the med. No hesitancy, feels his stream is strong, no dysuria,
feels empty after voiding. Nocturia 2-3 times. Reports edema in
genitals the past week. Itching in groin the past 2 days, the cream the
Dr. has been using has relieved some of the itching.
Peripheral vascular: Feet always feel cool, comfortable if he keeps
them covered. Denies parathesia, claudication, sores. Edema as
described earlier.
Musculoskeletal: Describes generalized weakness since cellulites. R
shoulder is “frozen” from a fall many years ago. Denies joint pain or
swelling.
Neuro: Reports good short- and long-term memory. No history of
seizures, tremors, or LOC. No hemiparesis, slurred speech or episodes
of decreased coordination. Has had dizzy spells since trauma to R side
of head in 1943. Dizziness comes on suddenly, no warning. No
change in frequency or duration of episodes. Has fallen with these
episodes. Episodes do not occur in relationship to activity, meals, or
environmental stimuli. Recovers after 5 min. rest, occur once every 12 weeks. No episodes since admission. Reports many previous workup of this, unable to find cause or treatment.
Hematologic: Denies bleeding or bruising. Blood transfusion as
outpatient since CLL diagnosed.
Endocrine: Denies excessive thirst, polyuria, intolerance to changes in
temperature. No changes in hat, glove, or shoe size.
Psychiatric: Feels his mood is good, denies depression.
Physical Exam
General Survey: Bright, alert elderly male, appears younger than
stated years. Transferred from VA Hospital in hospital garb via
wheelchair. Kerlix dressing on L hand and forearm. Cooperative,
responds appropriately to environmental stimuli. VS T 97.8 P70
20 BP 95/55 sitting Ht. 6’4” Wt. 184 lb. (about his norm)
R
Skin: Pale, warm, dry skin. Hair gray, thin. Nails on great toes
thickened, fingernails and other toenails non-thickened. All nails
neatly trimmed. Good skin turgor. L hand, wrist and forearm bright
pink in color with desquamatization. Small amt yellow serous drainage
on back of hand and outer aspect of arm, 2 inches below elbow. No
purulent or sanguineous drainage. Purpura in crural fold, scrotum,
and anal area. Crural fold moist, anal area dry and flaking.
Head: Normocephalic, facial features symmetrical. Scalp clear.
Eyes: PERRLA, EOMs intact. Conjunctiva pink and clear, sclera white.
Red reflex present, optic disc and vessels visualized, within nl limits.
Ears: Dk brown cerumen in R ear, TM pearly gray, L ear canal clear,
TM pearly gray. Auricles non-tender with movement.
Nose: Mucosa pink, no drainage. Septum slightly deviated to L. No
sinus tenderness.
Mouth: Lips dry, 2mm circular lesion on left and right side of lower lip.
Tongue red and glossy, 2mm circular lesions on tip and both sides of
tongue. Pharynx reddened, no white patches. No purulent drainage,
no bleeding. Uvula midline and mobile. Well-filling full upper and
lower plates. No open areas on gums or lining of mouth.
Neck: Supple, full ROM, thyroid non-palpable, trachea midline.
Lymph: No palpable lymph nodes in R cervical, supraclavicular,
axillary, or inguinal areas. 1-2mm nodes felt in L posterior auricular, L
submandibular, L superficial cervical and L axillary areas. No nodes
felt in L inguinal area.
Thorax/Lungs: Non-labored breathing. Lungs clear to auscultation and
percussion. No crackles or wheezes.
Cardiovascular: S1, S2 present, AP regular at 76. No murmurs,
gallops. Jugular veins not distended, no carotid bruit.
Abdomen: Distended and firm. Bowel sounds present all 4 quads.
LUQ tympanic to percussion, other quads dull. No tenderness, no
masses, no hepatosplenomegaly. No CVA tenderness. Unable to
detect any fluid waves.
Genitalia: Uncircumcised male, both testicles in scrotum. Penis
edematous, skin not taut or shiny. Scrotum soft, no edema.
Reddened skin as previously described.
Rectal: Sphincter tone intact, prostate palpable and not enlarged.
Stool for occult blood neg.
Peripheral Vascular: Extremities warm, pale, blanche with immediate
refill. Dorsalis pedis 3+/3+ bil. 2+ pitting edema in both legs to top
of thighs. No varicose veins. Homan’s neg.
M/S: Vertebral column straight. Abduction 45 degrees in R shoulder
from previous fall. Other joints have full ROM without swelling. Slow
to move L wrist and fingers due to cellulitis, does have full ROM.
Neurologic: Cranial nerves I-XII intact. Balance good in chair,
Romberg deferred. Leg strength 4+/5+ bil, R upper extremity 5+/5+.
DTRs intact in R arm and both legs. Deferred DTRs and strength in R
arm. Babinski neg bil. Sensation and coordination intact in all extrem.
Mental Status: Alert, oriented to time, place, and person. Speech
clear and articulate. Maintained eye contact, answered questions
quickly and appropriately.
Labs:
Hgb 10.2, Platelets 75,000 rest of CBC wnl
lytes wnl
albumin 2.9