Comprehensive: Rehab, Post LTH Revision

Comprehensive: Rehab, post LTH revision

Overview: 84 yo Caucasian female residing at XYZ for rehabilitation following removal of Austin-Moore prosthesis with LTH revision on 1-27-93. Experienced dislocation of new hip on 2-3-93 with closed reduction of dislocation performed in ER. Resident returned to XYZ 2-4-93. JB is returning home this afternoon. Niece will be living with her and her sister for a brief time to insure adequate safe recovery. Code status is DNR/DNI.

Chief Concern: Wants to avoid further complications of hip dislocation. Verbalizes proper precautions and reports that niece will be helping her with qd rehab exercises at home as well as assisting with personal cares and general housekeeping tasks. Demonstrates correct positioning of leg for flexion and use of walker. Independent with transfer out of bed to standing position. Is strong and balanced on standing with slow steady even gait.

Past History

General: Reports health as very good with no major illnesses.

Childhood Illnesses: Measles, chickenpox, whooping cough.

Adult Illnesses: (Information from physician H&P as client description of major health problems was limited, i.e. “heart problems, weak blood”) B12 and Fe deficiency anemia, annular calcification mitral valve, atrial fibrillation (no length of time of problems present identified).

Accidents/Injuries: Fall a number of years ago requiring LTHA.

Hospitalizations/Operations: LTHA x2 most recent 1/27/93, C-section 1946.

Psychiatric Illnesses: None.

Current History

Allergies: NKA.

Drug/Food Intolerance: OJ, tomatoes, all vinegar-based foods results in canker sores.

Immunizations: None recently.

Screening Tests: Full diagnostic workup in hospital 1/93, CBC 2/2/93 Hgb 9.0 with remaining components values WNL, pap and mammogram ? states she keeps up with them, last dental visit 3 yrs ago, no ophthalmology visit reports vision is good without glasses.

Environmental Hazards/Safety Measures: Uses walker for ambulation, waits for assistance from staff, call light within reach.

Exercise/Leisure: No information shared.

Diet: Eats balanced diet, cooks own foods, prefers fruits and vegetables, beans and whole grain breads. Minimal meat use. Occasional hamburger, chicken or fish. Drinks 2 pitchers of water daily. Drinks one cup coffee q a.m.

Sleep patterns: No problems, gets up 1-2 times to urinate.

Current meds:

1. ASA-EC 325mg, po qd
2. Multivit 1 tab qd
3. FeSO4 325mg po bid
4. B12 1000 mcg IM q mo
5. Tylenol #3 1-2 tabs q3-4 h prn
6. Digoxin 0.125mg, qd

No OTC use.

Habits: Non-smoking, no alcohol.

Family History

Mother died 87 yrs old rib tumor. Father died 52 yo throat CA. 12 siblings – three sisters remain alive (93, 85, 84 twin).

Psychosocial

Born and raised on farm in southern Iowa. Divorced after seven years marriage. One son who died of Hepatitis B in 1986. Work as a machinist for a firm in Davenport. retiring at age 62.

Review of Systems

General: No pain or fatigue, feels well.

Skin: No dryness, itching, sores, or bruising.

HEENT: No HA, vision or hearing problems. Does not wear glasses, states vision is excellent. Has full upper denture, own lower teeth. No vertigo, syncope, lightheadedness, tinnitus, nasal discharge, sore throat, or difficulty swallowing or chewing. Does have nasal stuffiness and rhinitis to cut grass.

Breasts: No lumps, tenderness, thickening or discharge.

Respiratory: No cough, wheeze, SOB, PND, orthopnea, dyspnea.

Cardiac: No chest pain, palpitations, tachycardia.

GI: No urgency, frequency, pain or hematuria, no vaginal itching, discharge or discomfort, no incontinence.

Peripheral vascular: No edema, intermittent claudication, leg cramps, cold feet, or numbness or tingling in hands or feet.

Musculoskeletal: No joint pain or stiffness.

Neurologic: No fainting, blackouts, drop attacks, seizures, weakness, paralysis, paresthesia, ticks or tremors.

Hematologic: No bruising, bleeding tendencies, or clotting abnormalities, does have anemia (B12 and Fe deficiency).

Endocrine: No thyroid-related problems or diabetes.

Cognitive/psychiatric: Occasional forgetfulness but feels she has adequate mental facility to perform daily problem-solving and decision-making tasks appropriately. No stress, nervousness, tension or depression.

Physical Exam

General: Neatly groomed elderly female lying supine in bed. Wt. 136, Ht. 5’4”. Alert and oriented, engaging in reality-based conversation. Speech clear and coherent. Mild urine odor.

Skin: intact with 15” incision line L hip, staples present. No inflammation along incision line.

HEENT: Normocephalic with no cervical lymph gland swelling. Sclera clear. PERLA. Conjugate movement of eyes through horizontal and vertical lines but does not move along diagonal lines. Does not hold lateral stare L or R, eyes bounce back to opposite side then center position. Reads words at distance and small print without glasses. Responds accurately to normal conversation voice tones. Strong gag reflex. Facial expressions symmetrical.

Breasts: Soft supple non-tender no lumps, thickening, or discharge.

Chest: Mild cervical kyphosis, LS clear with full even resp. Rib cage is long and large but not barrel-shaped.

Cardiovascular: No JVD or carotid bruits, systolic ejection murmur irregular rate/rhythm 94 bpm at rest rising to 140 bpm following 100 ft. walk declining to 100 bpm at 5 min rest post-exercise. PMI is wide and low from xyphoid to just below seventh rib R of MCL.

Abdomen: Soft, supple and non-tender with + BS all four quads. Umbilical hernia (since C-section). No splenomegaly/hepatomegaly.

GU: Deferred.

Extremities: No edema. Feet warm, flesh-tone with cap refill < 3 sec, immediate venous filling hands and feet, positive pedal pulses.

Musculoskeletal: FROM, mild crepitus in L shoulder.

Neuro: Equal very strong hand grasps, able to resist push pull forces arms and legs, minimal patellar response, negative Bibinski.

Cognitive/Psych: No deficits, appropriate affect.