SOAP: 89 YR OLD LIVING ALONE
Refuses meds, fall risk, pitting edema, cough, SOB,
fatigue, abdominal pain, poor vision
Background Information
This 89-year-old white female lives alone in a high-rise apartment.
She has no family. She has a history of CHF, atrial fibrillation, and
falls. She fell in a parking lot two months ago and was severely
bruised, but refused to let the paramedics take her to the hospital.
She has refused to go to the hospital in the past and does not want
her life extended. She is visited once or twice a week by a visiting
nurse. The nurse reports her apartment to be neat. The patient often
refuses to take her medications. She seems suspicious. She is on:
- Digoxin 0.125 mg daily
- Lasix 160 mg daily
- Prinivil 2.5 mg daily
- Cimetidine 800 mg daily
- Monthly vit. B12
- Tylenol 1000 mg t.i.d. prn
She refuses to take her potassium, and she refuses O2 therapy. She
often will not take her Lasix. A recent potassium level, iron panel, and
thyroid panel were within normal limits. Her hemoglobin was 12.7.
The visiting nurse reports that the patient has 4+ lower extremitypitting edema, which extends up to her thighs, a cough, and shortness
of breath. Her diet consists of many high-sodium prepared foods. Her
normal weight is 130 lb, but she has refused to be weighed lately.
She also complains regularly of abdominal pain that is unrelieved by
the Cimetidine. She has had difficulty sleeping in the past, but lately
has been rather lethargic and has been sleeping quite a bit.
A home health aid comes three days a week, and a volunteer comes
on Saturdays to help her shop. A social worker visits monthly and
calls her weekly. The social worker reports that the patient often
refuses help and does not want to pay even small co-pays for
equipment that would help her. She refuses to use a walker. She has
tried Meals on Wheels, but doesn’t like the food. The patient has
bilateral cataracts which she would like to have surgery for, but her
attending physician has recommended against the surgery because of
her inability to comply with the 4-6 week regimen of eye drops postop. Both the visiting nurse and social worker feel that she needs more
assistance and supervision than she has now, but they are pessimistic
that she will be willing to make any major changes. She is adamantly
opposed to leaving her own apartment and entering any type of
facility.
Patient has refused to answer questions in the past for Geriatric
Depression Scale and MiniMental, and is often uncooperative with
medical personnel. She seems to like her doctor and value his
opinion. She is not a good historian.
S:
1. She complains of fatigue, generally not feeling well. States has
been short of breath, more than usual, and has been coughing.
Gives conflicting information as to whether she sleeps with more
than one pillow. She complains of increased swelling of legs.
2. She also complains of abdominal pain, which is almost constant.
No nausea. The pain is sometimes dull and sometimes sharp. It
is epigastric and L lower quadrant. Eating does not relieve it.
She associates it with her back pain, which she says is also
almost constant. It is difficult to ascertain if she takes her
Tylenol or not. Back pain is a longstanding problem that has
been getting worse. Bowel movements are normal. Denies
bladder problems.
3. She complains of poor vision from her cataracts, and expresses a
desire to have surgery.
4. She admits to falls.
5. She complains of a rash on her arms that does not itch and a
rash on her back that does itch.
She refuses to answer any more questions so that a more detailed
symptom analysis can be done on her various complaints. She states
that all these questions are just a way of experimenting on old people,
and she only wants to see the doctor and get on with it.
O:
BP 92/70 P88 sitting. BP 90/70 P 90 standing. HT 5’1”, wt. 154 lb.
HEENT: Bilateral cataracts. ? JVD.
Heart rhythm irregularly irregular, rate 92, grade 3/6 systolic murmur.
Moderate kyphosis.
Lungs clear. Has an occasional dry cough. Abdomen soft, no masses,
no organomegaly, +BS, mild tenderness to deep palpation in the
epigastric area and L lower quadrant. Presacral edema is present, and
there is a 4+ pitting edema of the lower extremities extending upward
into the thighs.
Skin on lower extremities intact.
Unsteady gait.
There are some 3-4mm raised red papules on her right arm, and there
are similar larger raised red areas on her back, which appear to have
been scratched.
Geriatric Depression Scale 20/30. Refused to finish MiniMental after
getting first 4 questions wrong.