Assisted Living:
Post nasal drip, cough, weight loss, knee pain
L.M. is a 62-year-old Caucasian female resident of an assisted care
facility who is due for her annual physical exam. She has been at this
facility for 2 years. She is alert, oriented and cooperative with this
exam. Source of this history is both the resident and the chart where
indicated (*).
Chief Complaint
L.M. has 4 areas of concern today.
1. URI symptoms. L.M. has noticed increased post-nasal drip the past
2 days. She has had a non-productive cough, which is chronic for her
as she continues to smoke. The cough is not any different than usual.
She denies any fever, chills, sweating, or colored nasal discharge. It is
usually worse in the morning and improves as she moves around
during the day. She has not taken any medication for this.
2. Weight loss. L.M. continues to lose a pound per month. She
currently weighs 113 lbs with her ideal body weight for a woman who
is 5’4” is 120 lbs.
3. Arthritic pain. L.M. complains of bilateral knee pain. The pain has
been present for the past 4-6 months. Knees feel stiff and sore in the
morning upon arising. The pain does not radiate and improves after
she is up in her wheelchair and moving during the day. She has not
asked the staff for any interventions to date.
4. Health Maintenance needs. L.M. should be scheduled for annual
mammogram, flex sigmoidoscopy and lab work.
Past History
General state of health. L.M. states she has felt pretty good this past
year.
Childhood illnesses. Measles as a child, date unknown.
Adult Illnesses. Left sided hemiplegia with expressive aphasia and
seizure disorder. Bladder spasms. COPD. Stress incontinence. ASCVD
with myocardial infarction.
Accidents and injuries. Head trauma. Resulted in hemorrhage,
requiring craniotomy.
Hospitalizations/surgeries. Craniotomy. Hysterectomy. MI with
angioplasty RCA.
Psychiatric illnesses. None.
OB/GYN. 3 children via vaginal birth. Hysterectomy, unknown reason.
Current Health Status
Allergies. Macrodantin (hives).
Immunizations. Pneumovax 2 years ago. Influenza refuses, Td 5
years ago (*). Mantoux 1 year ago.
Screening. Last mammogram and pap 4 years ago. Refused last year
(*).
Safety measures. Staff assist with all ADL’s and transferring, uses
wheelchair to remain mobile. Always calls for assistance. Side rails up
x 2 while in bed.
Exercise/leisure activities. Attends activities 3 x/week. Enjoys bingo,
ceramics and crafts. Occasionally goes out on pass with family.
Sleep patterns. Sleeps 8 hours at night getting up once to urinate.
Rests every afternoon for approximately 1 hour.
Diet. Regular, low-salt diet. Eats 50% of meals (*).
Current medications.
EC ASA 5 gr q day.
Metoprolol 50 mg bid.
Niphedipine XL 30 mg q day.
Baclofen 20 mg bid.
MVI q day.
Nitro. 1/150 sl prn.
Acetaminophen 650 mg prn.
Tobacco/Alcohol/Illicit drug use. Smokes 2-3 packs/day. Drinks 1213 cups of coffee/day. No alcohol.
Family History
L.M. is currently married but resides at an assisted living facility. She
has 2 daughters, 2 sons and 4 grandchildren. Her father died of heart
problems in his 50s and her mother died from pneumonia at 77. She
is an only child.
Psychosocial History
L.M. is a permanent resident of the facility for the past 2 years when
her husband could no longer care for her due to his declining health.
She is of Irish descent, grew up in St. Louis and was educated through
high school. She worked at local department stores before marrying
her first husband and having 2 children. She describes him as a
drinker and an abuser. He pushed her down a flight of stairs once,
which resulted in the hemorrhage requiring a craniotomy and resulting
in her left-sided hemiplegia. She divorced him and married her
current husband and had 2 more children. She is Catholic and attends
services in the chapel. She states she has a good relationship with all
her children. She enjoys going out with them and likes to have them
visit. Her outlook on life is optimistic. She enjoys her current living
arrangement and visiting her family when able.
Review of Systems
a) General: Feels generally pretty good. Happy with the care she
receives.
b) Skin: Slightly dry this time of year, no open areas.
c) Head: Denies headaches or discomfort.
d) Eyes: Denies discharge, blurred vision or pain.
e) Ears: Denies earaches, infection or drainage.
f) Nose, Sinuses, Throat: Denies nosebleeds, sore throat, or sinus
pain.
g) Mouth: Denies mouth sores; dentures fit well.
h) Neck: Denies stiff neck, swelling, or tenderness.
i) Respiratory: Denies hemoptysis, or SOB. Chronic (> 10 years)
nonprod. “smoker’s” cough.
j)Cardiac: Denies chest discomfort, dizziness, or palpitations.
k) Gastrointestinal: Denies n/v, abdominal pain, diarrhea, or
constipation. Appetite good.
l) Urinary: Frequency and bladder spasms controlled with Baclofen;
denies burning or discomfort; wears panty shields during the day.
m) Genital: Denies masses, discharge, or discomfort.
n) Breasts: Denies masses, discharge, or discomfort.
o) Peripheral/Vascular: Denies numbness, swelling, or tingling.
p) Musculoskeletal: Bilateral knee pain (see CC); left arm contracted at
elbow without discomfort.
q) Neurologic: Denies bruising easily, never had a transfusion.
s) Endocrine: Denies heat/cold intolerances, skin changes, excessive
thirst.
t) Psychiatric: Denies feeling depressed, or suicidal. Denies seeking
help from abusive relationship with former husband, denies need to.
Physical Exam
General survey: L.M. is an alert, oriented female. Her speech is clear
and appropriate. Ht. 5’4”. Wt. 113 lbs. B/P 126/70. T 97.6. RR 24.
HR 68. Hgb 14.4 & TSH 3.2 1/95.
Skin: Pale, warm, dry and intact throughout. Tenting turgor on
forearms. Nails short and clipped.
Head: Right parietal indentation; well-healed craniotomy keloid; hair
thinning and dry.
Eyes: PEARL; right ptosis.
Ears: Canals clear, drums negative. Acuity intact to whisper test.
Nose: Mucosa pink, no drainage, no sinus tenderness.
Mouth: Upper and lower dentures, tongue midline, no lesions, uvula
midline, pharynx pink.
Neck/lymph glands: Trachea midline, thyroid nonpalpable, other nodes
negative.
Breasts: Negative for masses, discharge, palpable axillary nodes.
Thorax/lungs: Thorax symmetrical, lung sounds decreased without
wheezes, rales, or rhonchi, no CVA tenderness.
Peripheral/vascular: No edema, 3+ radial, 2+ pedal pulses.
Cardiac: S1, S2, negative for murmur, thrill, gallop, no bruit, no JVD.
Abdomen: Soft, flat, nontender, BS active x 4 quads. No hepativ or
splenomegaly, old keloid from hysterectomy.
Musculoskeletal: 4+ strength of right arm and leg, left leg flaccid, left
arm flexed and contracted at elbow, bilateral knee slightly enlarged
and tender to palpation.
Genitalia: Refused pap and bimanual exam, external genitalia WNL.
Rectum: Without drainage, breakdown, or external hemorrhoids.
Neurological: 2+ reflexes on right, 3-4+ reflexes on left, some
decreased sensation left lower leg, alert and oriented x 3, MMSE
27/30. GDS 4/30.