Assisted Living:
Post nasal drip, cough, weight loss, knee pain
L.M. is a 62-year-old Caucasian female resident of an assisted care facility who is due for her annual physical exam. She has been at this facility for 2 years. She is alert, oriented and cooperative with this exam. Source of this history is both the resident and the chart where indicated (*).
Chief Complaint
L.M. has 4 areas of concern today.
1. URI symptoms. L.M. has noticed increased post-nasal drip the past 2 days. She has had a non-productive cough, which is chronic for her as she continues to smoke. The cough is not any different than usual. She denies any fever, chills, sweating, or colored nasal discharge. It is usually worse in the morning and improves as she moves around during the day. She has not taken any medication for this.
2. Weight loss. L.M. continues to lose a pound per month. She currently weighs 113 lbs with her ideal body weight for a woman who is 5’4” is 120 lbs.
3. Arthritic pain. L.M. complains of bilateral knee pain. The pain has been present for the past 4-6 months. Knees feel stiff and sore in the morning upon arising. The pain does not radiate and improves after she is up in her wheelchair and moving during the day. She has not asked the staff for any interventions to date.
4. Health Maintenance needs. L.M. should be scheduled for annual mammogram, flex sigmoidoscopy and lab work.
Past History
General state of health. L.M. states she has felt pretty good this past year.
Childhood illnesses. Measles as a child, date unknown.
Adult Illnesses. Left sided hemiplegia with expressive aphasia and seizure disorder. Bladder spasms. COPD. Stress incontinence. ASCVD with myocardial infarction.
Accidents and injuries. Head trauma. Resulted in hemorrhage, requiring craniotomy.
Hospitalizations/surgeries. Craniotomy. Hysterectomy. MI with angioplasty RCA.
Psychiatric illnesses. None.
OB/GYN. 3 children via vaginal birth. Hysterectomy, unknown reason.
Current Health Status
Allergies. Macrodantin (hives).
Immunizations. Pneumovax 2 years ago. Influenza refuses, Td 5 years ago (*). Mantoux 1 year ago.
Screening. Last mammogram and pap 4 years ago. Refused last year (*).
Safety measures. Staff assist with all ADL’s and transferring, uses wheelchair to remain mobile. Always calls for assistance. Side rails up x 2 while in bed.
Exercise/leisure activities. Attends activities 3 x/week. Enjoys bingo, ceramics and crafts. Occasionally goes out on pass with family.
Sleep patterns. Sleeps 8 hours at night getting up once to urinate. Rests every afternoon for approximately 1 hour.
Diet. Regular, low-salt diet. Eats 50% of meals (*).
Current medications.
EC ASA 5 gr q day.
Metoprolol 50 mg bid.
Niphedipine XL 30 mg q day.
Baclofen 20 mg bid.
MVI q day.
Nitro. 1/150 sl prn.
Acetaminophen 650 mg prn.
Tobacco/Alcohol/Illicit drug use. Smokes 2-3 packs/day. Drinks 12-13 cups of coffee/day. No alcohol.
Family History
L.M. is currently married but resides at an assisted living facility. She has 2 daughters, 2 sons and 4 grandchildren. Her father died of heart problems in his 50s and her mother died from pneumonia at 77. She is an only child.
Psychosocial History
L.M. is a permanent resident of the facility for the past 2 years when her husband could no longer care for her due to his declining health. She is of Irish descent, grew up in St. Louis and was educated through high school. She worked at local department stores before marrying her first husband and having 2 children. She describes him as a drinker and an abuser. He pushed her down a flight of stairs once, which resulted in the hemorrhage requiring a craniotomy and resulting in her left-sided hemiplegia. She divorced him and married her current husband and had 2 more children. She is Catholic and attends services in the chapel. She states she has a good relationship with all her children. She enjoys going out with them and likes to have them visit. Her outlook on life is optimistic. She enjoys her current living arrangement and visiting her family when able.
Review of Systems
a) General: Feels generally pretty good. Happy with the care she receives.
b) Skin: Slightly dry this time of year, no open areas.
c) Head: Denies headaches or discomfort.
d) Eyes: Denies discharge, blurred vision or pain.
e) Ears: Denies earaches, infection or drainage.
f) Nose, Sinuses, Throat: Denies nosebleeds, sore throat, or sinus pain.
g) Mouth: Denies mouth sores; dentures fit well.
h) Neck: Denies stiff neck, swelling, or tenderness.
i) Respiratory: Denies hemoptysis, or SOB. Chronic (> 10 years) nonprod. “smoker’s” cough.
j)Cardiac: Denies chest discomfort, dizziness, or palpitations.
k) Gastrointestinal: Denies n/v, abdominal pain, diarrhea, or constipation. Appetite good.
l) Urinary: Frequency and bladder spasms controlled with Baclofen; denies burning or discomfort; wears panty shields during the day.
m) Genital: Denies masses, discharge, or discomfort.
n) Breasts: Denies masses, discharge, or discomfort.
o) Peripheral/Vascular: Denies numbness, swelling, or tingling.
p) Musculoskeletal: Bilateral knee pain (see CC); left arm contracted at elbow without discomfort.
q) Neurologic: Denies bruising easily, never had a transfusion.
s) Endocrine: Denies heat/cold intolerances, skin changes, excessive thirst.
t) Psychiatric: Denies feeling depressed, or suicidal. Denies seeking help from abusive relationship with former husband, denies need to.
Physical Exam
General survey: L.M. is an alert, oriented female. Her speech is clear and appropriate. Ht. 5’4”. Wt. 113 lbs. B/P 126/70. T 97.6. RR 24. HR 68. Hgb 14.4 & TSH 3.2 1/95.
Skin: Pale, warm, dry and intact throughout. Tenting turgor on forearms. Nails short and clipped.
Head: Right parietal indentation; well-healed craniotomy keloid; hair thinning and dry.
Eyes: PEARL; right ptosis.
Ears: Canals clear, drums negative. Acuity intact to whisper test.
Nose: Mucosa pink, no drainage, no sinus tenderness.
Mouth: Upper and lower dentures, tongue midline, no lesions, uvula midline, pharynx pink.
Neck/lymph glands: Trachea midline, thyroid nonpalpable, other nodes negative.
Breasts: Negative for masses, discharge, palpable axillary nodes.
Thorax/lungs: Thorax symmetrical, lung sounds decreased without wheezes, rales, or rhonchi, no CVA tenderness.
Peripheral/vascular: No edema, 3+ radial, 2+ pedal pulses.
Cardiac: S1, S2, negative for murmur, thrill, gallop, no bruit, no JVD.
Abdomen: Soft, flat, nontender, BS active x 4 quads. No hepativ or splenomegaly, old keloid from hysterectomy.
Musculoskeletal: 4+ strength of right arm and leg, left leg flaccid, left arm flexed and contracted at elbow, bilateral knee slightly enlarged and tender to palpation.
Genitalia: Refused pap and bimanual exam, external genitalia WNL.
Rectum: Without drainage, breakdown, or external hemorrhoids.
Neurological: 2+ reflexes on right, 3-4+ reflexes on left, some decreased sensation left lower leg, alert and oriented x 3, MMSE 27/30. GDS 4/30.