SOAP: Assisted Living, hypertension, DJD, breast
mass, cognitive impairment, incontinence
Client is a 96-year-old African-American female who enters this
assisted living facility with the following health concerns: H/O
hypertension, H/O DJD/gait disturbance, H/O cognitive impairment,
newly discovered L breast mass.
S:
1. Hypertension: Client unable to name medications she takes or
reason. Companion whom she was living with offered (from
chart) that client has been taking Dyazide and Klor-Con 20 meq
daily for unknown length of time. Denies dizziness, tolerating
Dyazide well.
2. DJD/Gait disturbance: Has been taking Feldene without
difficulty. Denies GI discomfort. Denies almost all symptoms of
DJD – joint pain, stiffness. Only a few minor “aches and pains.”
Needs walker to walk – “What do you expect for 96?” Unable to
recall how long she has been using walker. Vague history of falls
(per companion, on chart).
3. L breast mass discovered several weeks ago on physician’s
exam. No SBE. No discomfort or nipple discharge. Unaware of
mass. No mammograms. No family history of breast cancer.
4. Cognitive impairment: Admits to problems with memory.
5. Incontinence: Has been having more difficulty “lately” (unable
to be more specific) with bladder control. Denies dysuria. Is a
problem primarily at night, as she must walk down the hall to
use the toilet. No difficulty with bowels.
O: Very pleasant, cooperative, positive. Alert, oriented to person,
place, knows day of week, month, year, city. Cannot give meaningful
history, and was unable to respond appropriately to an attempted
discussion of advance directives.
Neck: No lymphadenopathy, bilateral carotid bruits R > L. Neck veins
flat.
Heart: 72, regular rhythm, murmur of aortic stenosis. Lungs clear.
Breasts: Firm, moveable mass 1/3” x 2” upper inner quadrant L
breast. No nipple or skin changes, no nipple discharge. R breast –
some irregularity but no discrete masses. Axillae negative. Both
breasts mildly tender to palpation.
Abdomen: Soft, non-tender, no masses or hepatosplenomegaly.
+BS. LE edema 1+ to mid-calf on R, 1+ ankle edema on L. Good
range of motion of all joints, no swelling except ankles. Walks with
walker with shuffling gait.
Blood pressure: Has ranged from 112/78 to 150/70 over past
several weeks with one reading of 170/90.
Labs: 4/3/95. Hgb 10.8, MCV 97, TSH 0.95, glucose 100, Cholesterol
216, K 4.4, Na 140, Cl 103, CO2 27. BUN 18, creat. 1.0. Normal
chest x-ray.