Comprehensive: Extended care, femoral neck fx,
Parkinson, back pain, wgt loss, axillary lump
Introduction:
GM is a 75 y/o white female admitted to the ECC unit for a short stay
s/p L femoral neck fracture and internal fixation. Fracture sustained
1/7/96 after fall in home of unknown cause. Surgical repair detained
until 1/10 r/t pneumonia, which has resolved. GM live alone in the
community and will need to be independent on DC. Admission H&P.
Information from pt and chart. Pt good historian.
Chief complaints:
1. “I’ve been having freezing of movement for the last 6 month.”
Occurs daily, most frequently before dose of Sinemt. Will be walking
then suddenly can’t move, lasts for 5 min, then is able to move. Med
makes it better. New symptom. States is taking med as ordered, 4
times per day. Usually sees neurologist q 6 mth, hasn’t seen 1 yr,
would like to see soon. Calls Parkinson’s one of her boyfriends, always
there. Has been able to manage the symptoms, not bother her,
except freezing concerns her. States strength, ROM, and coordination
L arm not as good as R because of Parkinson’s.
2. Incisional pain with movement in bed and lie in one position more
than 30 min. Pain sharp and local scale 6/10. Not constant. Not
asking for pain med. One took few days ago made her goofy, not
want to take again. Would try Tylenol. Moving around helps pain.
Pillow between knees makes it worse.
3. Lower back pain if walk more than 4-5 blocks R side back hurts.
Has seen a chiropractor 1-2 times a month for over 10 yrs with relief.
Not seen last 3 yrs since husband’s death. Never had massage. Not
taking meds. Uses Bengay in A.M. after lying in bed and if walks a lot
with relief, 3-4 times per wk. Bothering now since in hospital because
been in bed a lot. Feels tight. Pain local across lower back, feels stiff,
not radiate down legs or into buttocks. Denies any specific injury to
area, has had multiple falls (see accidents).
4. “I want to get out of here and walk around. I’m not used to being
cooped up.” Used to getting out and around. Feels trapped in
hospital, not been off unit or outside. Would like to “get away for a
while.”
5. Lump under R arm and bumps on face. Lump under R arm comes
and goes, happens 2-3 times per year. Lasts 2-3 months then either
pops it or has lanced, not remember when or how often. Current lump
been present 3 wks. No tenderness, burning, itching, heat, redness.
Bothersome, not interfere with activity.
6. “I have not been able to sleep all night since my husband died 3
years ago.” Able to fall asleep, but wakes up early and unable to fall
back to sleep. Goes to bed 11 p.m., wakes up 3-4 a.m. Not get out of
bed, just lie there. Has tried warm milk with pepper and salt, not
helped, not taken med. Naps during day because tired, 1-2 hr in
afternoon daily. Drinks 6 cups coffee daily, not think problem, “makes
me drowsy.” Used to drink more coffee when younger. When
husband was alive, took care of him for last 5 yrs of his life.
Sometimes had to get up during the night. Beginning to bother her,
now feels tired all the time, no energy since been in hospital. Not
slept well in here either.
7. Dry skin and scalp ever since moved in 1980. Dryness on legs and
arms, used different types of lotion “what’s on sale” once a day for last
15 y. Lotion helps for about a day. Worse in winter. Not big water
drinker, drinks 2 glasses of juice, milk, of water a day. Drinks 6 cups
coffee. Tried Selsen Blue on scalp once for 1 mth 3 y ago, used once a
week, not help. Hasn’t tried another kind of shampoo. Washes hair 2
times per wk.
8. Non-intentional weight loss of 20 lb over last year.
9. Watery eyes when reading. For last 4 yrs when try to read for more
than 30 min eyes water, need to stop. After 30 min better and can
read again. Irritating, loves to read. Last eye apt 1991 was told that
had minor cataracts, no surgery advised. Not been back to eye
doctor. Would like to be able to read more. No pain in eyes or
difficulty in vision.
10. Calluses on feet, nails need trimmed. Calluses bottom of feet
make it painful to walk. Had them periodically last 10 yrs. Have
calluses and toenails trimmed every mth. Has been 6 wks now, needs
to be done. When trimmed not painful. Wears good shoes (not
available to examine).
11. Respiratory. When lying on back breathing feels heavy, last 10
yrs. Sleeps on 2 pillows. Better when sitting up. Has slept on 2
pillows for 10 yrs. Since in hospital breathing tight. Has been on
inhaler for 10 yrs. Only use as needed, 1-2 times per week. Sees
respiratory specialist q 6 mth. Able to walk .5 block without puffing.
Not want O2 or more medication. Feels breathing not limiting her
much, does what she is able, not interfering. Denies any chest pain,
dizziness, blueness of hands or feet. Does not climb stairs, uses
elevator. Has smoked for 60 yrs, 1 pack per day, filters. Did try to
quit once about 7 yrs ago when husband had HA, lasted 1 wk. Has cut
down recently in last 3 mth to .5-.75 packs a day. States has no
desire to quit and knows the consequences. “I enjoy it. In fact, I
haven’t had one since I came in here and I miss it. I’m going to ask for
my cigarettes this afternoon.” Denies cough or pain with deep
breathing.
Past History
1. General state of health: Relatively healthy throughout life.
“Parkinson’s has affected me a lot.”
2. Hx childhood illnesses: Measles, chicken pox, whooping cough, no
mumps.
3. Adult illnesses:
a. Multiple Pneumonias: First 1943. Six times since. Unsure of
all dates. 1991 – viral, hospitalized San Diego, ca while caring for
brother-in-law. Most recent 1/7/96 on current hospitalization.
b. Parkinson’s disease: Diagnosis 1978. Currently on Sinemet to
control sx.
c. Hx rectal polyps: 1993, resolved.
d. Hx DJD spine: Currently not taking meds for pain.
e. Hx nephrolithiasis: Year unknown, resolved.
f. Hx pericecal abscess from infected diverticula: Year currently
unknown, bowel resection, resolved.
g. Hx weight loss unknown origin: 1/1995, 141 lb. 1/1996 119
lb. (current).
h. Hx severe uterine bleeding and clotting: Endometriosis with
bilat salpingo-oophorectomy and hysterectomy 1961, resolved.
i. S/P Fx L hip: 1/7/96, complicated by pneumonia & period of
post-operative confusion. Walked independently post op day 1 without
assistance in room, risk for fall, poseyed at night.
4. Accidents/Injuries: MVA 1936, lost 4 front teeth. 4 falls – 1943 fell
down flight of stairs when at school, no injuries; 1946 – fell down
basement stairs, thought door led to outside, no injuries; unknown
year – fell at farm, no injuries; 1/7/96 – fell in apt, fx L hip
5. Hospitalizations/ Surgeries (see Adult Illnesses): 1980 rash of
unknown cause or type.
2. Psych Illness: Hx depression with “pseudo hallucinations”
diagnosed 1993 after husband’s death 1992 and discovery that sister
dying of cancer. Saw dead husband in apt. on weekly basis for 2.5 yr.
Gero-psych at VA saw VG for bereavement. 12/3/95 VG felt no longer
depressed. Never on medication. Saw psych every 2-3 months for
almost 3 yrs.
Current Health Status
1. Allergies: Tetracycline – Measles-like rash, nausea. Sulfa drugs
– vomiting, sores on skin.
2. Immunizations: Pneumovax, 10/95. Flu shot 10/95. Last
tetanus unknown.
3. Screening: Mantoux, unknown. Creat, CBC, lytes, T4, TSH, GLU,
CHOL, WNL 7/7/95. WNL. Dental not known. Eye exam 9/9/91
slight cataracts, not operable yet. H&P, 7/7/95. Hearing eval,
unknown. Flex sig, lower, rectal polyps, upper, neg, 1/93. EKG,
WNL, 8/79. Heme cult neg 1/10/96. Neurologist, 1/95.
Respiratory specialist, 1/5/96. Pelvic exam & pap smear, not
found, pt not remember last exam, “been
PAGE MISSING HERE
Religious beliefs: Not Christian. Believes in god and spirits.
Outlook present/future: Feels lucky, is positive about future.
Code status: FULL
ROS:
1. General: Denies chills, fever. Feels fatigue since surgery at all
times, not have pep had before fall.
2. Skin: Denies rashes, recent changes moles, birthmarks, pruritus.
See C.C.
3. Head: Denies headaches, tenderness. See C.C.
4. Eyes: Denies diplopia, eye pain, redness. Vision good. Wears
glasses. See C.C.
5. Ears: Denies hearing loss, tinnitus, vertigo, tenderness & itching.
6. Nose/sinuses: Denies postnasal drip, nosebleeds, tenderness.
7. Mouth/throat: Full dentures. Denies bleeding gums, pain, oral
ulcers, loose teeth, difficulty swallowing or chewing, sore throat,
hoarseness.
8. Neck: Denies pain, limited ROM, swollen glands.
9. Breasts: Denies tenderness, discharge, lumps. Not do regular
self breast exam.
10. Respiratory: Denies sputum, wheezing. Denies occupational
exposures. See. C.C.
11. Cardiac: Denies chest pain or pressure, pain L arm, pain
between shoulders, palpitation, pedal edema, HTN, heart murmur,
hyperlipidemia.
12. GI: Denies nausea, vomiting, diarrhea, constipation,
hemorrhoids, belching, peptic ulcer disease, flatus, abdominal pain.
Stools qd-qod.
13. GU: Denies dysuria. Denies vaginal pain, discharge, burning,
sexually transmitted diseases. She & husband were not sexually
active for 15 yrs before his death. No current interest. Denies
incontinence.
14. Neuro: Denies dizziness, syncope, seizures, parathesias. See.
C.C.
15. PV: Denies claudication, cramping, Raynauds, coldness of feet
or hands, varicose veins, phlebitis, changes in color hand or legs.
16. Muscul-Skel: For ROM see & strength C.C. Denies osteoporosis.
Ambulates independently at home. SBA in hospital.
17. Heme: Denies easy bruising, blood transfusion, anemia.
18. Endo: Denies polyuria, polydypsia, thyroid problem, temp.
intolerance.
19. Psych: Mood good. Denies any depression or anxiety.
Motivated to return to home.
Physical Exam
General: VG pleasant & cooperative, talkative. Thin, small frame.
Alert & oriented. P = 80. BP = 110/60. R = 20. Wt = 115. Ht = 5’3”.
1. Skin: Pale, warm, dry, thin, poor turgor, multiple nevi present.
Skin forearms and legs dry with minimal flaking. No birthmark.
Ecchymosis around L hip incision. Incision dry, staples intact, without
redness, swelling or warmth.
a) L hand 0.5 cm round mobile nodule, flat on top, well
demarcated edges, white in color, mobile, without warmth or redness
b) Callus bottom R foot proximal to great toe, hard, yellow in
color, 0.5 cm round, well demarcated edges.
c) Toenails long, toes dry & foul smelling, no redness or
discharge between toes, skin intact.
d) Mobile primary lesion under R arm on midline of thorax,
without warmth, redness or tenderness, 0.25 cm round, mobile dry
pea-like texture. Fingernails trimmed & polished.
2. Head: Normocephalic. Large amt coarse black-gray hair, without
dryness or scaling. Scalp and skull without masses or lesions. Face
symmetrical, pink, smiling, equal smooth movements.
3. Eyes: Sclera white, without discharge. PERRLA. 6 cardinal fields of
gaze intact. Visual acuity exam 20/20 with bifocal glasses. Eyes
aligned, brows thick and symmetrical. Conjunctiva pink, sclera white,
cornea and iris normal. Red reflex present. Fundus visible, optic disk
normal. No arcus senilis.
4. Ears: External ear pink without masses, lumps or lesions bilat.
Canals pink bilat. Tympanic membranes visualized bilat. No drainage
bilat. Hearing normal to whisper test.
5. Nose/sinuses: Without drainage, patent, symmetrical, mucosa
pink. Frontal sinuses tender bilat on palpation, maxillary sinuses
nontender.
6. Mouth: Lips pink, symmetrical, moist, without lesions or masses.
No fillings, full dentures. Gums and buccal mucosa pink uniform,
without bleeding, masses, lesions or discoloration, gingivitis, tongue
midline, gag reflex normal. TMJ without crepitus or pain.
7. Neck: Trachea midline. Lymph nodes nonpalpable. Thyroid
nonpalpable. Trachea midline. Without JVD. ROM WNL.
8. Breasts: Symmetrical, pendulous, nodular texture, without masses
or discharge, axillary nodes nonpalpable. Skin pink. Nipples without
discharge, axillary nodes nonpalpable.
9. Lymph nodes: No lymphadenopathy.
10. Thorax and lungs: Thorax symmetrical, lungs clear, no
adventious breath sounds. No tenderness, masses, CVA tenderness.
No tactile fremitus. No sternal retraction. No SOB with activity,
standing or transfers. No O2 present. No coughing.
11. PV: Radial, femoral, popliteal bilat, pedal and post tibial bilat,
normal rate, smooth and regular symmetrically. Feet and hands warm,
pink, without discoloration. Capillary refill fingers and toes 1 sec. No
varicose veins or edema. Neg Homan’s sign.
12. Cardiovascular: Reg. apical pulse normal amplitude, smooth, 80
BPM. No thrill, lift, heaves, murmur, JVD, carotid bruit. Normal heart
sounds supine and side lying position. S1 and S2 audible in L 2nd and
3rd intercostal spaces, no gallop or S4.
13. Abdomen: Flat and soft, bowel sounds active x 4 quads without
tenderness. Normal tympanic percussion throughout. No
hepatosplenomegaly, tenderness, masses, distended bladder. Without
pulsations, lesions, masses or umbilical abnormalities. Multiple striae.
2 scars, 1 midline from naval to pubis, 1 R of midline naval to pubis.
Stool guaiac neg.
14. Musculoskeletal: Strength equal bilat UE, WNL. Grip strength
equal bilat. No joint swelling or deformities. Pain in L hip with
movement. R LE stronger than L. Decreased mobility L hip. Full ROM
R LE. Full ROM L knee & ankle. Joints stable. No kyphosis. Full wt
bearing. No pain with movement of UE. No pain with movement R
hip. Pain with change of position and sitting in L hip. No pain hip
standing. Pain in R quadratus lumborum & extensors with moving
from sitting to standing and with lying in bed. Tightness of lower
extensors & trigger points on R with palpation. Relieved with direct
pressure to trigger points.
15. Genital/Rectal: Pelvic exam deferred at this time r/t no
equipment on unit. On inspection external genitalia normal in color.
Hair distribution normal for age, color gray. Labia without masses or
lesions. Skin intact. No recto- or cystocele present.
16. Neurological: MMSE = 24. Cranial nerves intact 2-12. Follows 3step command. Sensation grossly intact to sharp and dull throughout.
UE reflexes 2+, LE reflexes 2+. Sitting balance good, Rhomberg
normal. Finger to nose slow but deliberate and coordinated bilat.
Resting tremor of hands, L > R. No pill rolling, shuffled gait, or jawmouth movements at rest. Speech normal volume and articulation.
Cogwheel rigidity present bilat, L > R.
17. Psych: GDS = 6. Mood elevated, pleasant and cheerful, laughing
and smiling.