COMPREHENSIVE: Nursing Home
N&V, dementia, hearing loss, hypertension, DJD,
personality disorder
PJ 88 y.o. Caucasian male, residing in a Nursing Home. Source of the
history is from the patient’s chart and nursing home staff. Patient is
unable to provide history.
CC: Patient offers no complaints. Nurse indicates patient has had 3
episodes of nausea and vomiting in the past 6 hours. First emesis
noted in the AM, patient’s garbage can had emesis with small parts of
food particles; the other two emesis’ were while patient was up to the
bathroom with the nurse in the AM after drinking some juice and a
little later after he had drank Sustacal. Patient is afebrile, no other
symptoms, no change in behavior. On the patient’s floor there has
been an outbreak of the flu with several of the residents having
symptoms of nausea, vomiting, and low-grade fevers, which resolves
within 24-48 hours.
PAST HISTORY
General State of Health: Has steadily been declining since diagnosed
with dementia in 1991.
Childhood illnesses: Per wife had ordinary childhood illnesses.
Adult illnesses:
1. Dementia, probable Alzheimer’s disease. Diagnosed 1991, CT
scan done at that time to rule out other causes.
2. Bilateral hearing loss.
3. Prostate cancer 1987.
4. Essential hypertension 1993.
5. Degenerative joint disease.
6. Alcohol abuse started 1940s, quit 1990.
7. Pneumonia 9/95.
8. Ruptured right eardrum secondary to ear infections.
Surgeries/Hospitalizations:
1. TURP 1989.
2. Prostatectomy/lymphadenoctomy 1989.
3. Bladder surgery 1989.
4. Right hip replacement 1/95.
5. Bowel obstruction 2/95.
6. Pneumonia 9/95.
Psychiatric illnesses: Passive-aggressive personality disorder with
delusional paranoid disorder diagnosed at onset of diagnosis of
dementia.
Accidents and Injuries:
1. 1948 back injury secondary to fall, no medical attention sought.
2. Right tibial fracture 12/91.
3. Right humeral neck fracture 7/93.
4. Right hip fracture 1/95.
5. Left ankle sprain 6/95.
CURRENT HEALTH STATUS
Allergies: None known.
Immunizations: Pneumovaccine 2/94. Flu shot 10/95. Tetanus 4/94.
Screening tests: Ophthalmologist last exam unknown, dentist 5/95,
audiologist no record.
Safety: Staff use lap belt while P.J. is in wheel chair. Has had a
history of falls, although R hip fx due to another resident pushing the
patient, gait is unsteady and patient is not safe ambulating on his own,
impulsive and poor priopioreception. Standby assistance with
transferring into chair and into bed. Use of walker and assist of one
for use of bathroom.
Environmental Hazards: Potential for falls.
Diet: Soft low-sodium diet. Sustacal supplements 5x day, ice cream
bid, started 2/95 when patient had significant weight loss with hip
surgery and bowel obstruction (wt. 128 lbs 2/95).
Current medications:
- Lorazepam 1 mg HS prn for agitation restlessness at noc
- EC ASA 5 gr. QD started 1/95 prophylactic S/P right hip
surg.
- Nifedipine XL 60 mg QD for HTN
- Zantac 150 mg HS also started when he had his Right hip
surgery, MOM 2 T QD
- Bisacodyl supp. 10 mg prn
- Al/Mag Simeth II 30cc Q 4 hr prn
Tobacco: 2-3 PPD 40 years quit 1985.
Alcohol and illicit drugs: History of alcohol abuse 5-6 beers every
weekday with binges on the weekend. Wife stated drinking started he
returned from service. Quit 1990. No known illicit drug use.
FAMILY HISTORY
Mother died of gallbladder disease at age of 50. Father died at age of
80 from complications after falling. 10 siblings, wife is unsure of
number living or dead. Death of siblings from cancer and heart
disease. 6 children alive and well.
PSYCHOSOCIAL HISTORY
Retired boiler worker. WWII veteran, 2 years of service, one of which
was in Italy, the other in the U.S. Patient is married to second wife or
40 years, 6 children: 2 daughters, 4 sons, and 14 grandchildren, all in
good health. Four of his children do not keep in contact with him due
to relational problems stemming from alcohol abuse. Lutheran
background, although was not active. According to the patient’s wife
prior to his placement in the nursing home the patient was living at
home with wife until 2/94. At that point it was too difficult for her to
handle, he would wander and he was a reckless driver. He also was
paranoid that his wife was having an affair, was delusional.
REVIEW OF SYSTEMS
Non-contributory patient is unable to answer questions due to severe
dementia.
PHYSICAL EXAM
Vitals: Wt. 179# Ht. 5’10” T 98.8 BP 140/82 R 24 HR 84
General: Patient is alert, has good eye contact, smiles and laughs. In
trying to interview him, I was unable to get meaningful responses.
Dress and grooming not fastidiously neat, but not sloppy either. Hair
combed, unshaven, oral hygiene poor. Patient is cooperative with
exam. Patient is unable to answer orientation questions and unable to
recall past history.
Skin: Intact, warm, dry. No varicosities, no edema, normal turgor, no
signs of dehydration.
Head: Normocephalic, hair thick gray, evenly distributed. No lumps or
lesions. Face symmetrical.
Eyes: PEARRL, red reflex present, bil. cataracts seen, unable to
visualize retina patient moving head during exam. Sclera and
conjunctiva without discharge or errythema. Patient able to read large
print, unable to read newspaper print - when asked if it is blurry,
patient says “yes.”
Ears: Auricles aligned symmetrical, without lesions. Canals small amt.
cerumen. Right TM healed perforation, left TM intact, bony landmarks
intact. Patient responds only to louder vocalizations, does not hear
whisper or soft voice.
Nose: Nares patent, mucosa red, clear nasal drainage, septum midline.
No maxillary or frontal sinus pressure.
Mouth and throat: Teeth stained gray-tan with plaque buildup, 10
lower teeth and 13 upper teeth with missing molars. Gums with
errythematous border directly above teeth. Tongue and buccal
mucosa pink, without lesions. Pharynx without errythema.
Neck: Trachea midline, thyroid nl size without nodules. No
lymphadenopathy.
Chest: Lungs clear, resp. 24 even, no accessory muscles used. Thorax
symmetrical. Spine without kyhoscoliosis. No CVT.
Cardiac: Apical pulse palpated at 5th ICS, no heaves or thrills. No JVD.
Heart tones, rate and rhythm regular, S1 S2, without murmur or
gallop.
Peripheral vascular: No carotid, abdominal, or femoral bruits.
Peripheral pulses symmetrical, radial +2, brachial +1, dorsalis +2,
post-tibials and popliteal +1. No varicosities. Negative Homan’s.
Abdomen: Midline incisional scar from below umbilicus to symphisus
pubis. Bowel sounds all four quadrants. Abdomen soft, flat, no
masses or tenderness. No splenomegaly. Liver edge firm, smooth
palpated 3 cm below rib cage.
Musculoskeletal: Tremors right hand tardive dyskinesia secondary to
Haldol use back in 1991. Extremities strength equal bilaterally with
full range of motion. Ataxic gait, patient is compulsive with getting up.
Genital/Rectum: Uncircumsized, foreskin retractable, no discharge or
lesions, scrotum and testicles intact without lumps or swelling.
Rectum without masses, no palpable prostate. Hemmocult negative
stool.
Neurologic: Alert and oriented self only. No recall of recent or past
events. MMSE done 11/20/95, score 11/30 previous 4/94 score
13/30. Unable to answer questions on orientation, recall, calculation
or spelling WORLD, to draw shapes and minimal ability to follow
commands. GDS done 11/20/95 score 6/30. Babinski reflex negative.
Patellar reflexes brisk +3, symmetrical, other DTR intact +1 and
symmetrical. Unable to do Rhomberg with patient’s unsteadiness
standing. Gait ataxic, finger-to-nose slow and deliberate. Unable to
perform finger to finger or do hand pronation/supination. Sensation
extremities intact.