Comprehensive: Board and Care, dementia, urinary incontinence, left breast mass, DJD
Pt. is a 95 year old, frail African American female, widowed, no children, no close relatives, recent admission to a board and care facility (9/92). Pt. is DNR/DNI.
Information obtained from the chart is marked with a *
Current Problems
- Dementia (*), type not designated. Over past year, patient’s memory has gotten progressively worse, to the point where she was unable to care for herself in the senior high-rise. A distant cousin states that she became increasingly “feisty,” “sassy,” and “nasty,” which was very unlike her normal behavior. Her forgetfulness was causing problems with hygiene and pt. was experiencing weight loss.
- Increased Urinary Incontinence: Since admission pt. has experienced an increase in episodes of urinary incontinence. These generally occur at night and she sometimes goes in convenient receptacles (e.g., wastebasket, vase). She denies any pain or burning, “just has to go.” Incidents have become more frequent over last month.
- Left breast mass: 2x2 cm, mobile mass, located medial to the L nipple. Lump noted in old records as of 1993, no action taken at that time. Pt. seen by surgeon on 8/31/95 who recommended biopsy and removal. Currently awaiting decision of distant cousin to proceed.
- DJD (osteoporosis): Right thumb base joint swollen and painful “lately.” Pain localized. Hurts, but “not that bad,” when she walks with her walker. Can’t remember taking anything for pain. “Just aches.” Feels better when she is not putting pressure on it.
General State of Health: Frail, but relatively stable.
Childhood diseases: Cannot remember, not in medical history.
Adult diseases:
- HTN – no past history of first occurrence or treatment.
- DJD – no past history available.
- Cognitive impairment – progressed over past year.
Operations/Hospitalizations: Medical history unavailable. Pt. unable to remember.
Current Health Status
Allergies: No known allergies.
Immunizations: Pneumovac, flu shot, tetanus, all current.
Screening tests: Mammogram, 1995, Mantoux, 1995, negative. Lab work 10/95 normal Hgb., TSH. Potassium 3.2.
Environmental Hazards: Lives in small room with bed, chair, chest of drawers
and miscellaneous furniture. Pathway open, but potential for injury is present.
Use of safety measures: Pt. uses a walker at all times when she is up, even in room.
Exercise and Leisure Activities: Pt. walks from room to lounge area, watches television, visits with other residents and sometimes reads.
Sleep Patterns: (*) Patient sleeps well, but does get up 1-2 times per night to urinate. Sleeps about 7 hours per night.
Diet: (*) Pt. is eating a regular, mechanical soft diet, and eats ½ to ¾ of every meal. She eats independently.
Current Medications:
- Dyazide, one capsule, every day.
- Piroxicam 10 mg, daily.
- KCL, 20 meq, q daily.
Tobacco/Alcohol Use: No usage.
Family History
(*) Pt. has no family history on chart and is unable to remember. She has no near relatives.
Psychosocial History
Home Situation: Lives in Board and Care home and is supervised in ADLs.
Significant others: Has a cousin who helps her make health decisions, or makes them for her if she is unable.
Daily life: Follows the routine of the board and care home. Little outside stimulation.
Religious Beliefs: Has a strong Baptist faith.
Outlook on present/future: Is ready to go when it is her time.
Review of systems
General: Feels she is “slowing down.”
Skin: Denies any itching, open areas.
Head: Denies headaches, dizziness.
Eyes: Denies pain, itching, discharge. Wears reading glasses.
Ears: No hearing loss, pain, itching.
Nose/Sinus: No nasal drainage, facial pain.
Mouth/Throat: Says she is “growing new teeth.” Is able to eat well with “ground-up food.” Denies mouth sores, sore throat.
Breasts: Denies breast pain or drainage.
Respiratory: Denies cough, doesn’t “go fast enough to get short of breath.”
Cardiac: Denies chest pain.
GI: No constipation, diarrhea, heartburn.
Urinary: Denies burning, pain. Has frequency (see Current Problems).
Genital: No itching.
Peripheral Vascular: Feet sometimes “cool.”
Musculoskeletal: Knees and hips sometimes “ache,” wrist “hurts,” (see Current Problems.)
Neurologic: Denies numbness in hands or feet, weakness. Admits to “bad memory.”
Physical Exam
General: BP 118/60, HR 80 and regular. Weight, 110 lbs, up from 106.5 on admission. Height, 5’2”.
Skin: Dry area under breasts, no open lesions, bruises.
Head: Symmetrical, no lumps or bruises.
Eyes: PERRL, eye exam not done.
Ears: No discomfort on palpation of external ear, no otoscope available for inner ear exam.
Nose: Nasal passages clear, membrane pink, moderate amount of hair.
Mouth/Throat: No sores or lesions under tongue, oral mucosa pink and intact. Pt. has several of her own teeth, no dentures.
Neck/Lymph nodes: No palpable nodes in neck, supraclavicular, groin or axilla.
Breasts: Discrete mass felt in left medial breast. No dimpling, discharge from nipple. No pain on palpation. No masses palpated in right breast. No palpable nodes.
Respiratory: Lungs clear to auscultation. No adventitious sounds. Air movement to all lobes. Pt. able to speak whole sentences with one breath. Able to ambulate to lounge without apparent DOE.
Cardiac: Slight murmur (aortic stenosis) auscultated. Dependent edema (1+) in R lower extremity, less in L. Carotid, radial, femoral pulses present and equal, pedal pulses present but not as strong. BP controlled well with dyazide.
GI: Bowel sounds positive in all quadrants. No pain on light or deep palpation. Abdomen soft, non-distended. No aortic bruit.
Female genitalia: Not examined at this time. Pt. refused.
Peripheral Vascular: CMS positive in all extremities. No vascular discoloration in lower extremities.
Musculoskeletal: Slight kyphosis, gait steady, but slow and shuffling, with walker, able to get up out of chair. Able to raise arms to shoulder height.
Neuro: Alert, oriented to self and present time. Short and long-term memory impairment present. CN II-VII intact. DTRs difficult to assess, 1+ - 2+.
Psych: Pt. cooperative, no behavioral problems.