Comprehensive: Nursing Home, back pain,
constipation, memory loss
History and Physical
The resident is an 81-year-old retired restaurant owner. She has been
widowed 5 years and has resided at the long-term care facility since
1990. She has a “no code” status.
Present Illness
Medical Dx:
Chronic brain syndrome
Chronic back pain
Chronic constipation
Degenerative joint disease
L nephrectomy, partial R nephrectomy secondary to
hydronephroma
S/P fx R femur (displaced R supracondylar and suprapatellar R
femur fx, 1990)
S/P R mastectomy
S/P R venous thrombus 1990
Chief complaint:
Back pain
Constipation
Short-term memory loss secondary to dementia
Surgeries:
R mastectomy
L nephrectomy
R partial nephrectomy
ORIF R knee (12/90)
Current Health Status
Allergies: Sulfa, Hydrochlorathiazide
Immunizations: Flu vaccination 10/92
Screening tests: TB test 6/88 (neg); dental exam 10/92; creat 1/92
Environmental hazards: Wheelchair bound, dementia, waist restraint
Exercise/Leisure: Enjoys cards, exercise, music, TV, spiritual activity
Sleep: Staff reports patient slaps self and side rails at night, especially
the first hour after being put to bed. Is verbally agitated at bedtime.
Diet: Mechanical soft.
Medications:
Methenamine .5 gm po bid
Cytotec 200 mg pot id
Feldene 20 mg po qd
DSS w/CAS 1 cap po bid
APAP 2 tab qid
PRN: bisacoydal supp qd prn
Alcohol and Tobacco Use: Current and past use unable to be
determined at this time.
Family History
Had 3 children, one child died in infancy. Son lives in XXX. Daughter
lives in XXX. Unable to determine medical family history, as patient
believes parents are still alive.
Psychosocial History
Has daily contact with relatives or group activities. Son and
granddaughter live close by. DJ and her husband owned and operated
a restaurant and tavern in town. DJ’s son currently runs the tavern.
At the time of this examination, DJ believes her husband and parents
are still living and that she will be going home. She is active in the
facility’s activities. Developmentally, she is age-appropriate with the
exception of her confusion.
Review of Systems
Skin: Denies rashes, nodules or open sores.
Head: Denies headache, head injuries.
Eyes: Denies vision loss, glaucoma, diplopia. Wears glasses.
Ears: Denies hearing loss, vertigo, tinnitus.
Nose: Denies sneezing, nosebleed, hay fever.
Mouth: Denies open sores, bleeding gums. Wears upper and lower
dentures.
Neck: Denies hoarseness, goiter, dysphagia.
Lungs: Denies wheezing, productive cough, hemoptysis, pneumonia,
asthma. Bronchitis documented 1990.
Heart: Complains of shortness of breath. Denies orthopnea, chest
pain, edema, heart attack, palpitations, hypertension.
Breasts: Denies lumps or discharge. States both breasts are present
(has had R mastectomy).
GI: Denies anorexia, vomiting, diarrhea, bleeding, nausea,
constipation, pain, jaundice (patient record indicates frequent
constipation).
GU: Denies frequency, nocturia, hematuria, polyuria, dysuria,
incontinence, infections or hernias.
GYN: Gravida 3, para 3. Postmenopausal.
Peripheral Vascular: States varicose veins. Denies leg cramps,
phlebitis.
MS: Denies pain, joint swelling, arthritis. States occasional back pain.
Neurological: Denies seizures, paralysis, numbness, tingling.
Blood: Denies transfusion history.
Endocrine: States thyroid difficulty, denies diabetes.
Physical Exam
General: Wt. 146 lb (6/93). Ht: 5’3”. BP 108/80. Requires total
assist in transfer to and from bed. Does not bear weight. At time of
exam, pt incontinent of urine.
Skin: Hair white, thin. Skin color pink, no rashes or lesions.
Eyes: Reads large print easily, able to read some small print. Sl
ptsosis L eye. Unable to elicit EOM. PERRLA. Opthalmic exam WNL.
Ears: R ear partially blocked with cerumen, L3/4 occluded. R TM WNL.
Hears whispered tones bilaterally.
Nose: Septum midline, no sinus tenderness.
Mouth: Lips moist, gums pink, non-edematous, tongue midline,
pharynx WNL. Upper and lower dentures intact.
Neck: Thyroid palpable, non-enlarged, trachea midline, no nodes
palpable.
Lungs: Respirations non-labored, lungs clear, good aeration, chest
shape normal.
CV: Sl. Systolic murmur auscultated, HS regular, no JVD, no bruits
auscultated. Ankle edema present bilaterally, L > R. Feet cool to
touch. Unable to palpate pedal or posterior tibial pulses.
Breasts: Left breast full, non-tender, soft, no masses palpated. R
mastectomy incision.
Abdomen: Large, soft, non-tender. Upper left incision extending to
back, 2” incision below umbilicus, midline pubic incision. Yellow/brown
skin tag present LLQ.
Genitalia: Labia and vulva normal for age. Pelvic exam deferred at
patient request. Urinary incontinence.
Rectum: Anal area reddened, no open areas. Rectal exam: Smooth
rectal wall, no masses.
MS: No deformities. Finger joints slightly enlarged but no deformity.
Unable to bear weight. Knees flexed during transfers. Unable to
adduct L leg. Able to raise L leg 90 degrees. R leg normal ROM.
Resistance to plantar flexion bilaterally.
Neuro: CN II-XII intact. Negative Romberg. Upper arm strength
strong and equal bilaterally. Lower extremities previously described.
Mental: Scored 11 of 30 on Mini-Mental exam. Uses waist restraint
while in wheelchair. Asks same question or made same comment
frequently during examination. Short-term and long-term memory
impaired.