Comprehensive: Nursing Home, Rash
PT. is an 85 yr. old white female, wheelchair bound, non-communicative resident of a nursing home.
Source: Resident, nursing staff, medical records, and granddaughter.
Chief Complaint: Nursing staff is concerned about new red linear rash on resident’s chest. Rash has appeared within past two days, and nursing staff has noticed resident scratching chest. There has been a recent outbreak of scabies at the nursing home, however, the outbreak was not on this resident’s floor, and she has received one KWELL treatment one week ago. Resident has had no known exposure to any residents or staff infected with scabies.
Past Medical History:
General Health: Good.
Childhood Illnesses: No information.
Immunizations: 5/88 neg. mantoux, 11/92 vaccine.
Adult illnesses: 3/90 disseminated herpes zoster.
Psychiatric Illnesses: None.
Operations: R cataract extraction with implant, 1979
Injuries: Hx of fractured wrist due to fall (again, unable to determine from the records the exact date, or which wrist, granddaughter states it was about 1986) forehead laceration due to fall, 7/90.
Hospitalizations: Childbirth x 3, 3/90 for above mentioned disseminated herpes zoster and for cataract operation.
Medications:
Sorbitol 30cc op BID
Lasix 40mg op DQ
Xanax .125mg QD
Niacin 50mg po QD
Dulcolax supp. One PR QD PRN
Lotrimin Cream topical PRN
Chlortrimentin 4-8mg po Q 6 hours PRN
MOM 15-30cc po QD PRN
Allergies: Keflex, Penicillin, Dyazide (unable to determine from records what type of reaction resident had to these drugs). Has adverse reaction to Haldol, Mellaril, Ativan. Resident also has hay fever.
Habits:
Diet: Resident is a total feed. Receives three meals a day in the dining room at the N.H.
Exercise: Resident is wheelchair bound, has received P.T. and O.T. in the past.
ETOH: Never.
Tobacco: Never.
Sleep: Nursing staff reports that resident takes two naps during the day and appears to sleep well during the night.
Family History:
Mother died age 70s had breast CA and CHF.
Father died age 70s had CHF and MI.
One brother died in infancy, accidental death.
One brother age 70s healthy.
One brother age 70s had mental illness and seizures.
One sister died age 60s accidental death.
One sister died age 50s cervical CA.
One daughter age 63 healthy except for hay fever.
One daughter age 61 recently had pancreatitis.
Psychosocial:
Resident was born in N.J. Grew up in Iowa. Married, had 3 daughters. Husband owned his own business and Pt. was a full-time housewife. She has 6 grandchildren, and 9 great-grandchildren, prior to placement at the home in 1988, she lived in her own home. She was active in Sons of Jacob and attended Temple. She enjoyed music and reading. She continues to enjoy listening to music. Family is very supportive, with her granddaughter seeing her daily, and her daughters seeing her several times a week.
Review of Systems:
General: Pt. has been relatively healthy throughout her adult life.
Skin: Hx of disseminated herpes zoster 3/90.
Head: No hx of head injuries.
Eyes: Has glasses but refuses to wear the, unable to determine last eye exam, bilat cataracts.
Ears: No hx, unable to determine last audiology exam.
Speech: Nonverbal due to several small CVAs over past 2-3 years. Speech path. Eval 9-93.
Nose and Sinuses: No hx.
Neck: No hx.
Breasts: No hx, pt. unable to do SBE.
Respiratory: No hx, last CXR 1990.
Cardiac: HTN x 10+ years.
GI: Occasional constipation – treated with stool softeners, nursing staff reports good appetite.
Urinary: Pt. incont. X 2-3 years, wears protective undergarments, no hx of UTI.
Genito-Reproductive: Unable to determine age of onset of menarche or menopause, para 2.
Musculoskeletal: In W.C. x 2 years, contractures in hips and knees.
Peripheral Vascular: No hx.
Neurologic: Several TIAs, non-communicative, demented.
Hematologic: Chronic anemia.
Psy: No hx.
Endocrine: No hx.
PHYSICAL EXAM:
General: Resident is in bed for exam, appears comfortable, smiles at questions and introductions, does not answer questions or follow commands except for responding “yes” when asked if she was born in N.Y. Pt. un-cooperative at times during the exam, pushing my hand away.
V.S.T.: 99 B/P 128/80 RR: 16 HR 69 Wt. 125# Ht: Not listed.
Labs 8/93:
Bun 51 K 3.5
Creat 2.3
Chol 248
Trig 96
HGB 10.5
Uric Acid 11.8
Skin: Pale, warm and dry. Several 2-3 cm linear red lines across chest, good turgor, no lesions noted.
Head: Gray hair, no lesions or deformities.
Eyes: Red reflex present, unable to check fields, acuity or extraocular movements, R pupil irregular, discs poorly delineated due to pt. being uncooperative with exam.
Ears: R canal clear, eardrum pink/gray and intact, L drum not visible due to cerumen impaction.
Nose and sinus: Nasal septum midline, no sinus tenderness, mucosa pink.
Mouth and pharynx: Lips pink and intact, upper dentures and lower partial plate, tongue midline, mucosa appeared pink and intact (with the small glimpse I got, as pt. was uncooperative).
Neck: Trachea midline, no nodes palpated, thyroid isthmus not palpable, appears to have normal mobility, pt. resisted PROM.
Nodes: No nodes palpated, no tenderness noted.
Thorax and lungs: Thorax symmetrical, CTA with decreased breath sounds throughout. Lungs resonant. Difficult to determine diaphragm level, as patient would not cooperate with taking deep breaths, but on normal inspiration, diaphragm descends 2-3 cm.
Heart: RRR, precordial impulse non-displaced, no murmur, gallops, carotid upstrokes normal, no bruits.
Breasts: Symmetrical, no masses, discharge or tenderness.
Abdomen: No masses, RUQ appeared tender, as pt. grimaced with palpation, liver 6-7 cm, BS x 4 quads, no aortic bruits.
Genitalia: No examined.
Rectal: External hemorrhoids, otherwise negative.
Musculoskeletal: Hip and knee contractures, unable to determine ROM in UE as pt. uncooperative, and would tense muscles as I tried to move extremities.
Neurological: Cranial nerves – Unable to be evaluated.
Motor: No weight bearing, + Babinski.
Sensory: Unable to determine.
Mental State: Pt. seemed tense, occasionally pushing me away, or holding my arm.