Comprehensive: Nursing Home, dementia, diarrhea

DOB: 3-17-13

March 14, 1995

ANNUAL H&P DICTATION – Completed/Dictated 3-9-95

CODE STATUS: DNR/DNI

This resident is an 81-year-old gentleman who is pleasant and cooperative but not a good historian due to his dementia.

CHIEF COMPLAINT: Resident has been having diarrhea according to his records for the past week, since the 24th of February. He has been having two to three large loose brown stools per day primarily in the evening and at night. He has no nausea, no vomiting, no decrease in appetite, no abdominal pain and no fever. He has some vague complaints of heart burn from time to time, pain in both groins and in both legs. These complaints are very vague and he is unable to elaborate or give any details. The resident feels that his diarrhea is due to eating too many apples. A conversation with the HST caring for him reveals that the resident has been seen very frequently during the past week at the fruit basket in the hall taking and eating fruit.

PAST HISTORY:

  1. Childhood illnesses: Thinks he had the usual childhood illnesses.
  2. Adult illnesses:
  3. Diabetes type II diagnosed in 1986, treated with oral hypoglycemics, has peripheral diabetic neuropathy.
  4. Gait disturbance. Began in 1986 after cholecystectomy, multifactorial and related to peripheral neuropathy, wheelchair bound since 1991.
  5. Hypertension. Present before admission in 1992, had hypertensive crisis in January 1994, blood pressure rose to 220/120, presently controlled on Metoprolol.
  6. Cataracts, bilateral extractions 1986, 1987.
  7. Dementia, probably Alzheimer’s. In January of 1994 RPR was negative, B12 and folate levels were normal.
  8. Heart murmur, present at least since admission, grade 2/6.
  9. History of lower extremity edema due to venous insufficiency. A two-dimensional ECHO in January 1994 showed normal left ventricle. Lasix was discontinued and Ted stockings were ordered.
  10. History of viral gastroenteritis. In January of 1990 was found on the floor of his apartment suffering from severe weakness. Later presumed diagnosis was viral gastroenteritis.
  11. Ileus or small bowel obstruction in January 1994. Had questionable GI bleeding with emesis of dark material, which was guaiac positive, and stools that were guaiac positive. No cause was found except possible a UTI. The episode resolved with IV fluids, nasal gastric suctioning and treatment for the UTI. A subsequent urine culture was negative. In November 1994 resident had another episode of guaiac positive emesis.
  12. Chest pain and MI January 1994. Begun on Metoprolol to control heart rate and also blood pressure.
  13. History of micro hematuria. Was evaluated by Urology in April 1994 with IVP and cysto. The work-up was negative.
  14. Incontinence probably secondary to diabetic neuropathy.
  15. Nodule in rectum. A 5mm submucosal nodule was found posterior in the lower rectum on 10-18-94 on flex sig.

PSYCHIATRIC ILLNESSES: None known.

INJURIES: None known.

OPERATIONS/HOSPITALIZATIONS: Hospitalized in1986 for a ruptured gall bladder.

CURRENT HEALTH STATUS:

  1. Allergies: No known allergies.
  2. Immunizations: 10-21-94 flu, no record of pneumovax or tetanus vaccine.
  3. Environmental Hazards: Falls.
  4. Safety Measures: Side rails on bed, use of Sara lift.
  5. Screening: Mantoux 4-25-94 was negative; no record of dental visit or audiology screening, last vision screening was in 1992.
  6. Leisure activities: Likes to watch TV in room or sit out in hall, refuses to go on outings.
  7. Exercise: Goes to physical therapy 3-5 times per week to walk on the parallel bars.
  8. Sleep: States he sleeps well.
  9. Diet: Liberal ADA.
  10. Tobacco: None.
  11. Alcohol: History of abuse from charts.

CURRENT MEDICATIONS:

  1. Nitroglycerin patch 5mg per 24 hours, apply 8 am, remove 6 pm.
  2. Glyburide 2.5mg daily
  3. Acetaminophen 5 grains 2 tabs hs daily and 1 or 2 q 4 hours prn
  4. Cimetidine 400mg bid
  5. Metoprolol 50mg 1 bid
  6. ASA 80mg 1 tablet daily

PSYCHOSOCIAL:

Resident has an eighth-grade education. He was born inNew Jersey. He is Catholic. At a young age he was taken to an orphanage by his father who never returned. He has no siblings and no known relatives. He has never married and has no children. He lived alone all of his life. He served in World War II. He did farm work and worked at a Meat Packing factory. He had a good friend who was quite close to him and looked after him the later years of his life. Resident has a positive outlook on life.

REVIEW OF SYSTEMS: A review of systems was attempted but not completed because the resident was unable to concentrate and his answers were not reliable.

PHYSICAL EXAM: Height 5’6”. Weight 221 pounds. Weight 1 year ago 205 pounds. Blood pressure 130/70. Pulse 78.

Skin: Warm and dry, no rashes, bruises or suspicious lesions, numerous seborrheic keratoses over the back, neck and head.

Head: Hair thinning, scalp and skull normal.

Eyes: Vision good in right eye but very poor in left eye; has corrective lenses but does not wear them. Unable to test EOMs or fields because resident does not cooperate. Red reflex seen in both eyes and vessels appear normal. Discs not visualized. PERRLA, conjunctiva pink, sclera clear.

Ears: Drums obscured by wax bilaterally, acuity good to whispered voice.

Nose: Mucosa pink, no sinus tenderness.

Mouth: Mucosa pink, poor dentition, tongue midline, no lesions on tongue or under tongue or on buccal surfaces, pharynx pink.

Neck: trachea midline, thyroid not palpable.

Lymph nodes: No palpable lymph nodes in neck, axillary, epitrochlear or inguinal areas.

Thorax and lungs: Thorax symmetrical, good expansion, lung fields resonant, vesicular breath sounds throughout, no adventitious sounds.

Cardiac: S1 S2 normal, no S3 or S4, systolic murmur heard at apex and left sternal border, no heaves, lifts or thrills.

Breasts: No nipple discharge or lumps.

Peripheral Vascular: Carotid, brachial, radial and femoral pulses strong and regular. Pedal pulses very faint. Mild lower leg edema, no bruits, normal JVP. Extremities warm, no pallor or cyanosis, no varicosities or calf tenderness. Homan’s negative.

Abdomen: Obese and symmetrical, large well-healed midline scar, bowel sounds normal, no masses or tenderness, no hepatosplenomegaly, no CVA tenderness.

Genitalia: No lesions or discharge on penis. Skin on scrotum and on perineal area reddened and tender. Most likely irritated from diarrhea. No testicular masses felt, although exam was limited because of tenderness of the skin of the scrotum. No inguinal hernia.

Rectum: No hemorrhoids, no masses, stool brown, prostate is smooth, firm, no nodules, no unusual tenderness.

Musculoskeletal: Range of motion normal, no joint deformities. Can wheel self in wheelchair. Transfers with Sara lift.

Neurologic: Cranial nerves 2-12 intact. Oriented to person and place. DTRs are equal, motor testing intact 5/5. Diminished sensation in stocking area of both feet. Finger-to-nose cerebellar testing slightly dysmetric with left hand. Babinski toes down-going. Mini-mental – 16/30.

Psychiatric: Unable to do Geriatric Depression Scale as resident is unable to comprehend and concentrate.

REHAB POTENTIAL: Fair.

DISCHARGE POTENTIAL: Poor.