Comprehensive: Nursing Home, hip pain, change in mental …



Comprehensive: Nursing Home, hip pain, change in mental status

Introduction: PK is an 80y white male, widowed who was admitted to the nursing home on October 13, 1992 following a pedestrian/motor vehicle accident, which left him unable to care for himself. Info gathered from resident, chart, and staff. PK has had a continuation of his dementia and has an altered cognitive status.

Chief Complaints/Hx Present Illness

1. L hip pain: Resident has had pain in his L hip since 1993 when he sustained injuries from a pedestrian accident. Worse with turning and transfers. Helped with Tylenol #3 and lying still. However, over the last month the pain has worsened and current dose of Tyl #3 not helping.

2. Change in mental status: Per staff PK has had a recent decrease in energy and increased lethargy over the last 1-2 months. He falls asleep during conversations and is unable to track conversation for longer than 5 min. His last MMSE = 24/30 on 4/22/94. JK states he has felt more tired than usual during the day and needs more naps in the last month. More energy in the evening, worse in AM, naps help. Increased confusion at night per staff.

Past history

1. General state of health: Generally healthy until accident 1993.

2. Hx childhood illnesses: Diphtheria, scarlet fever, not recall any other illnesses.

3. Adult illnesses:

a. CAD

b. Chronic atrial fib: controlled

c. Hypothyroidism: controlled synthroid

d. PVD

e. Dementia, Alzheimer’s type, exhibits disruptive behavior, yelling out and abusive lang to staff and residents

f. Vit B12 deficiency: controlled

g. Hx chronic osteomyelitis in L leg: no current swelling, redness

h. R central retinal vein occlusion

i. Hx TIAs

j. Hx chronic Pain: non-union L hip r/t ped accident 1993. Currently taking Tyl #3

k. Bilat glaucoma: betaxolol soln eyes

l. Hx detached retina: resolved, 8/95 with surgery

m. Hx venous status ulcers

n. Hx constipation managed on MOM, dulc, suppos & BAP

o. Alt skin status: current open area, Stage II on coccyx

p. Hx Traumatic head injury

q. Hx rectal itching: controlled

r. Hx urinary and fecal incontinence since admission. Managed with incontinence pads on at all times

4. Accidents/Injuries: Injured by exploding shells WWII. Sustained massive facial, abdominal, R wrist, L leg, L hip injuries.

5. Hospitalizations/Operations: Hospitalized many years recovering from war injuries. Underwent multiple surgeries including partial gastrectomy, skin graphing and reconstruction of face, reconstruction of R wrist, harbor hip arthropodous of L hip. Hospitalized 4/23 – 5/27/93 to recover from injuries sustained from MVA. 8/95 retinal repair.

6. Psych illness: Some paranoia and suspicion with staff for the last several months. Unclear starting date.

Current Health Status

1. Allergies: Thimerosal, penicillin and cortisporin (hives)

2. Immunizations: pneumovax 10/94. Tetanus not found in chart. Flu shot 11/95.

3. Screening: Mantoux 1993 neg. Creat, CBC, lytes WNL 9/7/95. Dental 8/30/95. Eye exam 9/20/95. H&P, 11/94. Hearing eval. No Flex sig in chart, Heme cult neg 11/94. Dig level = 0.5, 10/14/95. TSH 1/4/95 WNL. PT 9/7/95 19.4, therapeutic range. MCV = 81.9, 12/94.

4. Environmental hazards: Risk skin breakdown r/t amt of time spent in wheel chair, water mattress on bed & foam cushion on w.c. Overhead trapeze to decrease shearing with movement in bed.

5. Safety: Use Sara lift for transfers, SR x 2 while in bed. Waist belt in wheel chair, lapboard when up.

6. Exercise and leisure: Participates in 1:1 recreational therapy and music programs.

7. Sleep patterns: Goes to bed 2200, woke up in past with episodes of yelling 2-3 times per night, not happened last month. Takes 2-3 naps qd, 1-2 hr after breakfast, lunch and before supper.

8. Diet: Reports moderate appetite. Milk intolerance, can drink skim milk. Takes sustical supplements 3 x/d. Currently fed by staff. Eats 100% tray. On reg. low salt diet. Gets 200 cc fluids qd.

9. Current meds:

a. Lorazepam 1 mg qhs

b. Tyl #3, 1-2 tabs BID& q 4 hr PRN

c. Ascorbic acid 250 mg qd

d. 1000 mcgs B12 injection q mth

e. Diltiazem CD 120 mg qd

f. Docusate suppos qod

g. L-Thyroxine, 0.1 mg qd

h. MOM 2 TBS qd

i. Coumadin 5 mg 2x/wk, coumadin 2.5 mg 5x/wk

j. Digoxin 0.125 mg qd

k. Calcium 250 mg TID

l. Betaxolol 0.5% opthal soln 1 gtt UO BID

m. Haloperidol 1 mg qhs

n. KCL 16 meq Bid

o. Dibucaine ointment 1% rectal itching PRN

p. Criticaid to buttocks BID

q. Aquaphor lotion to dry skin on legs BID

10. Tobacco: Not smoked since service.

11. Alcohol/Illicit drugs: An occasional glass of wine. No illicit drugs.

Family Hx

Father died age 55y mine cave accident. Mother ? TB unknown age. Twin brother died in his 60s, unsure cause. Sister, age 65 y, respiratory problems.

Psychosocial Hx

P.K. was a post-master. Married 35y. Major in army during WWII and Korean War, attended Adjutant General school. No children. One cousin and niece have POA. Cousin visits wkly.

Daily life: Spends most of time in room. Occasionally sits in hallway.

Important experiences: Experience as Major in army.

Religious beliefs: Catholic, occasionally attends service.

Outlook present/future: Not have positive outlook on present or future.

Functional Status

ADLs: dep with dressing, max assist with transfers

IADLs: niece and cousin POA

AADLs: only attend therapies on 1:1 basis r/t disruptive behavior

DC and rehab potential: Poor

Code status

DNR/DNI

ROS

1. General: Denies chills, fever, wt. change. Increased fatigue over the last several months, naps make it better, worst in AM. Better in evening.

2. Skin: Dryness in arms and lower legs, lotion helps. Had > 5 y, unable to be more specific. Denies rashes, recent changes moles, birthmarks, lumps, pruritus.

3. Head: Denies headaches, flaking scalp, tenderness. Some scalp itching, 1x/wk, not bothersome, nothing helps.

4. Eyes: Denies diplopia, eye pain, redness, recent change vision. Wears glasses.

5. Ears: Denies hearing loss, tinnitus, vertigo, tenderness and itching.

6. Nose/Sinuses: Denies postnasal drip, nosebleeds, tenderness.

7. Mouth/Throat: Dentures. Denies bleeding gums, pain, oral ulcers, loose teeth, difficulty swallowing or chewing, sore throat, hoarseness.

8. Neck: Denies pain, limited ROM, swollen glands.

9. Breasts: Denies tenderness, discharge.

10. Respiratory: Occasional SOB with activity. Naps and rest, moving slowly helps, worse after eating, has had for 2 months. Denies sputum, wheezing, asthma, SOB. No chest x-ray in chart. Denies occupational exposures.

11. Cardiac: Denies chest pain or pressure, pain L arm, pain between shoulders, palpitation, orthopnea, pedal edema, HTN, heart murmur, hyperlipidemia, dizziness or blackouts.

12. GI: Denies nausea, vomiting, diarrhea, constipation, hemorrhoids, belching, peptic ulcer disease, flatus, abdominal pain. Incontinent of stools, reg BM q2-3 d.

13. GU: Denies dysuria, testicular pain, penile discharge. Unaware of urge to void. Wears full pads when up and pad on bed when lying down.

14. Neuro: Denies dizziness, syncope, seizures, parathesias, weakness, tremor. Per staff increased episodes of striking out at staff and confusion at night.

15. PV: Denies claudication, cramping, Raynauds, coldness of feet or hands. Varicose veins, phlebitis, edema.

16. Musculoskeletal: Decreased ROM legs r/t pain. Pain 7 our of 10, on scale 1-10. Denies osteoporosis. Unable to ambulate.

17. Heme: Denies easy bruising, blood transfusion, anemia.

18. Endo: Denies polyuria, polydypsia, thyroid, temperature intolerance.

19. Psych: Denies depression, anxiety. Frustrated with staff not being meticulous. Feels room not clean enough and staff sit around too much. Has felt this way since admission, but nothing being done about it. Demanding and suspicious, verbally disruptive and inappropriate per staff.

Physical Exam

General: Resident very thin man, much muscle wasting in lower extremities. Interview done with JK in bed, very somnolent.

VS: T + 97.8, P = 70 irregular, R = 20, BP = 146/80, wt = 142.7 and stable

1. Skin: Pale, warm, moist, poor turgor. Lower legs dry and flaking. Multiple nevi on arms and chest. No birthmark. Nails trimmed. Stage II area, 1.0 cm x 1.0 cm on center coccyx, Criticaid cream present.

2. Head: Normocephalic. Small amt gray hair, bald without dryness or scaling. Scalp and skull without masses.

3. Eyes: Sclera white, without discharge. PERRLA. Unable to test vision r/t ubtunded. Eyes and brows symmetrical. Fundus not visualized. Arcus senilis.

4. Ears: Small amount cerumen present in R ear. R ear canal patent. Ear canal pink bilat without drainage. Tympanic membranes pearly gray, translucent with light reflex visible bilat. External ear pink without lesions, masses bilat.

5. Nose/Sinuses: Without drainage. Lumens narrow and deformed from plastic surgery, visualized to 0.5 cm symmetrical, mucosa pink.

6. Mouth: Lips pink, symmetrical, dry, fillings. Gums and buccal mucosa pink uniform, without bleeding or discoloration. Gingivitis, tongue midline, normal gag reflex. Slow swallow.

7. Neck: Trachea midline. No lymphadenopathy. Thyroid non-palpable. Without JVD. ROM WNL.

8. Breasts: Without masses. Nipples without discharge, axillary nodes nonpalpable.

9. Lymph nodes: No lymphadenopathy.

10. Thorax and lungs: Thorax symmetrical, lungs clear, no adventious breath sounds. Respirations easy and non-labored, however shallow.

11. PV: Pulses radial, femoral, and popliteal bilat. Pedal or post-tibial bilat. Feet and hands warm, pink, without discoloration. Capillary refill fingers and toes. No edema, varicose veins. Spenco boots on feet and sheep skin between toes.

12. Cardiovascular: Irregular apical rhythm, without thrill, lift, murmur, JVD, carotid bruit. S1 S2 audible, no gallop or S4.

13. Abdomen: Symmetrical, rounded, large scar on L midline and L upper quadrant. Soft, bowel sounds active x 4 quads. Tympany percussed over entire abdomen. No hepatosplenomegaly, tenderness, masses, distended bladder.

14. Musculoskeletal: Decreased strength upper extremities. Major surgical defect in calf muscle on R leg. ROM decreased neck, L hip, and legs. Difficult to bend r/t pain and guarding. No redness or swelling of joints, deformities. Min kyphosis. Non-wt. bearing. Difficulty turning in bed, needed max. assist.

15. Genital/Rectal: Penis and scrotum normal size, testicles free-floating. No redness or discoloration. No drainage, lesions, masses, hernia, tenderness, hemorrhoids. Perineal area pink without irritation, prostate size symmetry, firm or hard, nodules. Stool present, guaiac neg.

16. Neurological: MMSE = 9. Resident ubtunded and needed frequent awakening to finish assessment. Poor recall. Finger-to-nose slow but deliberate. Cranial nerves intact 2-12. 3-step command. Sensation grossly intact to sharp and dull throughout. UE reflexes, 2+ LE reflexes unable to illicit r/t pain. Sitting balance poor. Gait and Rhomberg deferred.

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