Comprehensive: 91 Yr, living alone, hip and leg pain, assessment of developmental stage
IDENTIFYING DATA: Mrs. HG. is a 91 year old, widowed, white female who lives alone in an apartment.
SOURCE OF HISTORY: Self, reliable with some memory lapses.
CHIEF COMPLAINTS: Osteoporosis.
PRESENT ILLNESS: HG. has been bothered with osteoporosis for several years, which is most painful in her right hip and leg. The pain is throbbing at times, mild most of the time but worse before she exercises and “gets going.” It hurts the most when she stands. Little relief from Tylenol. Most effective treatment is her walking the long apartment halls 3 x a day.
PAST HISTORY (as told to me by client; no chart available): General health has always been good, although describes self as “not a strong person.” At about age 12 she was hit by a car and broke her right leg; recovery took a long time (1 year) after which she had to learn to walk again. Recalls being anxious as a child, very active, and thinks she had the usual childhood illnesses. Was treated for depression and hospitalized x 1 to “get off all her pills.” Within last 10 years hospitalized for removal of two benign lumps on left breast. Cut ligaments across top of right foot when she fell into a kitchen fan over ten years ago. Believes some of her foot pain is related to that accident.
CURRENT HEALTH STATUS
Allergies: None.
Immunizations: Has not taken flu shot and doesn’t think she has had pneumovax.
Screening tests: Mammogram many years ago.
Environmental Hazards: Difficult for her to get out of tub so she sponge bathes. Has removed rugs, furniture that block her path for getting up at night.
Exercise/Leisure: Walks halls 3 x a day. Enjoys blackjack and bingo, birthday celebrations and other group activities with people in her apartment complex.
Sleep: Gets approximately 7-8 h per night. Often gets up to go to the bathroom x 1.
Diet: Makes own breakfast and lunch and gets meals-on-wheels for main dinner. Diet balanced and adequate in nutrients. Has housekeeper shop for her.
Medications: Cardiazem 30 mg bid; Colace 1 tab bid; Zantac I qhs; Neptazane ½ tab in a.m. and hs; Tylenol ii qhs.
Tobacco: None, never smoked.
Alcohol/Drug: None.
REVIEW OF SYSTEMS
General: Usual weight in adult lifetime was 110#; now weighs 93#.
Skin: No rashes or other changes except those attributable to aging.
Head: Denies head injury; has occasional headache over past one month believed to be due to humid weather.
Eyes: Wears glasses; denies pain, redness, blurred vision.
Nose and Sinuses: Denies sinus trouble, nosebleeds, or frequent colds.
Mouth and Throat: Reports having two teeth removed last week that was extremely painful; denies bleeding from gums, sore tongue or throat.
Neck: Denies having goiter, swollen glands, or pain.
Breasts: Denies pain, nipple discharge. Reports two benign lumps removed from left breast over 10 years ago; does not do self-examinations.
Respiratory: Denies cough, asthma, bronchitis, emphysema or pneumonia.
Cardiac: Reports some “heart problems” for which she is taking pills; denies HTN, dyspnea; controls ankle edema with her “water” pill.
Gastrointestinal: Reports problems with constipation with fairly effective control using Colace and diet, and sometimes supplements with Metamucil and mineral oil; reports hemorrhoids that periodically giver her pain; denies heartburn, nausea or vomiting; reports good appetite; denies abdominal pain or liver problems.
Urinary: Denies polyuria, burning or pain on urination; reports nocturia x 1; denies urinary tract infections.
Genital: Denies postmenopausal bleeding; denies discharge, itching, sores or lumps; one normal pregnancy; currently not sexually active.
Musculoskeletal: Reports overall arthritis with joint pain and stiffness that is most prevalent in right hip and leg; denies any swelling or redness; reports limitation in movement in upper arms (difficult to cook) and lower extremities (walking long distances).
Peripheral Vascular: Denies leg cramps or varicose veins.
Neurologic: Denies seizures, paralysis, numbness or loss of sensation; reports has used amitriptyline in past for slight tremors.
Hematologic: Denies anemia or bleeding problems.
Endocrine: Denies thyroid trouble, diabetes, diaphoresis, excessive thirst, hunger, or polyuria.
Psychiatric: Reports being a nervous child and having some periods of depression during her marriage.
PHYSICAL EXAMINATION
General: Mrs. HG. presents as a short, pleasant, thin elderly woman with striking kyphosis, an alert mind, carefully groomed, and in no apparent distress.
Vital Signs: BP 146/78 P: 72 R: 16
Height and Weight: 5’1”; 93#
Skin: Warm and dry but pale; excessive wrinkling with significant loss of subcutaneous fat evident. Thick head of permed hair, slightly graying. Scalp and skull normal.
Eyes: Reads sentences clearly at 14”; fields full by confrontation; sclera clear; conjunctiva pale; EOMs intact; PERRL.
Ears: Left ear canal clear with negative drum; right contains cerumen, unable to visualize tympanic membrane; acuity diminished on right and left; need to use loud voice to be heard.
Nose: No sinus tenderness; septum in midline with pink mucosa.
Mouth: Recent removal of two teeth with present teeth in good repair; no bleeding, sores on tongue or gums; tonsils absent; gag reflex present; uvula in midline.
Neck: Trachea in midline. No lumps felt on thyroid.
Lymph nodes: None palpable.
Thorax/lungs: Lungs resonant; breath sounds clear with no added sounds; barrel chest yet good expansion.
Cardiovascular: Carotid pulses normal; no carotid bruits; regular rhythm with S1 and S2; no S3 S4 or murmur present.
Breasts: No masses or tenderness; no nipple discharge; small scars from removal of two benign lumps on left breast.
Abdomen: Protruding, round, soft; bowel sounds present; no masses or tenderness; liver span 6 cm in right midclavicular line; no CVA tenderness.
Genitalia: (Refused pelvic exam.) No discharge noted; no redness, sores, or welling of vulva.
Rectum: (Refused.) small hemorrhoids; no redness or bleeding.
Peripheral vascular: No stasis pigmentation or ulcers; no calf tenderness; DP and PT pulses palpable; no pitting edema of feet or ankles.
Musculoskeletal: Painful restriction of shoulder joints, right and left; unable to easily raise hands above head or reach behind herself; wrist flexion and extension slightly painful but no deformities; painful restriction of hip range of motion worse on right than left; loss of normal lumbar curve with rounded thoracic convexity (kyphosis).
Neurologic:
- Cranial nerves: II-X and XII intact; XI – sternomastoids and trapezii diminished in strength
- Gait: Stooped over with small, careful steps that favor her right side giving the appearance of a slight limp.
- Motor: No involuntary movements; muscle wasting consistent with normal aging changes; strength slightly diminished in hands and legs.
- Sensory: Pain, light touch, and sterognosis intact.
MENTAL STATUS
Appearance/Behavior: Well-groomed with appropriate behavior.
Speech/Language: Intact; reads 3-4 novels per week.
Mood: Appears somewhat depressed; life is lonely; cannot participate in activities the way she used to; “it is hard to be alone so much of the time.”
Thought/Perception: Intact.
Memory: Unable to remember details of earlier life correctly but knows she isn’t accurate.
Attention: Excellent.
Higher cognitive functions: Judgment, abstraction intact.
B&C – Client Strengths, Developmental Level, Socio-cultural Needs
HG. is amazingly healthy at first glance for a 91-year-old female. She is quite independent in her living arrangement even though she requires a housekeeper to clean, shop and do laundry for her. Her physical health is quite good with the exception of mild cardiac insufficiency and osteoporosis. Her resultant problems of impaired mobility, pain, and edema are under fairly effective control with medication.
HG’s primary social support is her neighbor and friend whom she is in contact with daily. Her one son, daughter-in-law and two grandchildren appear peripheral to her life even though she talks to her son two or three times a day.
HG. is Jewish and believes that once she dies, life ends. “This is what there is.” Her religion does not seem to comfort her in times of loneliness or pain. Based on Erikson’s developmental theory, HG. is in the stage of integrity vs. despair, working out the meaning of life. She reports having loved life very much – she thoroughly enjoyed the intense involvement she had socially – belonging to clubs, going to many drama events, traveling in a circle of friends who “lived the good life” and had similar interests. Now she feels sad that that part of life is over, gone. I sense some hopelessness because she has no sense of “looking forward to” in her life. She never talks about sharing in the milestones of her grandchildren or the hope for great-grandchildren. She speaks negatively of her daughter-in-law and shuns any kind of relationship with her. This, of course, compromises a warm loving relationship with her son as well. I believe she has regrets of not having a larger, more loving family. She shared some very personal childhood information that I promised not to disclose. This information confirms for me the struggle she has had over the years to find worth in herself. On the one hand, she is incredibly strong, assertive, and richly blessed in her life. On the other, she feels like “something is missing” and she cannot do her life differently now.
In summary, based on developmental and aging theory, HG. has suffered many losses in her life – husband, only having one child, friends, home – all of which have necessitated her to grieve. Loss theory states that when a person doesn’t grieve in a healthy way then that leads to morbid grief, which is exhibited, by depression, irritability, hopelessness, and/or apathy. I have to wonder if some of this is reflective of Mrs. HG’s situation.