Comprehensive: insomnia, pain in shoulder, visual deficit ...



Comprehensive: insomnia, pain in shoulder, visual deficit, fall risk

Date of History: Obtained during home visits 2-19-93; 2-25-93; and 3-11-92.

Identifying Data

Name: M.O..

Age: 87

Sex: Female

Race: Caucasian (non-Hispanic)

Place of birth: Urbana, IL

Occupation: Retired

Religion: Unitarian

Source of Referral: Identified through local church. Primary physician Dr. Jones 321-1234.

Source and Reliability of History: Client. Overall reliability fair, is questionable historian. Requests that the medical record be reviewed for dates of illnesses, hospitalizations, medication use, etc.

Chief Complaints:

1. Sleep: Insomnia x 2 years. Sleep pattern – bed at 10-11 p.m., falls asleep after 1-2 hours, up 2-4 x to void, aware after 2-4 hours of sleep. Self-help measures of warm shower and classical music not successful. 2/16/93 started Doxepin 10 mg at hs with good results – falling asleep more readily and sleeping longer.

2. Pain: Pain in R shoulder, finger joints, knees re: osteoarthritis and muscle weakness. Arthritic-type pain for > 20 years, B/L knee replacement in 1979-1980. Shoulder pain described as throbbing, increases in supine position, at night, limits ROM, decreases when sitting up or laying on L side. Describes finger and knee joint pain as alternating between extreme sharp, stabbing and aching, dull pain. Relieved by massage of joints; Advil 200 mg 6 per day. Unsuccessful treatments included mineral ice and paraffin wax.

a. Pain: Ice pick (sharp and stabbing) generalized pain in L side of chest and L breast region since thoracic surgery in 1992. Increases after sitting for several hours, stair-climbing. Usually relieved by Advil, however 1x week Talwin NX 50 mg 1-2 and Diazepam 2 mg.

3. Visual Deficit: Hx macular degeneration and glaucoma. Reads thick black bock print of 1” height with glasses, magnifying glass, and bright direct light. Limits activities including reading mail, finances, socialization. Quit classes for the visually impaired when she lost her transportation. Is exploring options for live-in assistance through church and community resources.

4. Lightheadedness and Falls: Sensation of “lightness” after stair-climbing. Occasional dizziness when changing position, aware of precautions of moving slowly. Fall in winter 1992 with possible loss of consciousness (see hospitalizations). History of 2-3 falls per year for 3-4 years. App. 6 months ago fell in bathroom; 2 months ago fell in kitchen. Describes both episodes as very fast with no warning, unaware of changes in vision or loss of consciousness. Limits socialization (afraid to go outside). Purchased walker 3/10/93 but has not yet used.

Past History

General State of Health: Describes previous health as “blooming and athletic.”

Childhood Illnesses: Chickenpox, mumps, and measles. Denies scarlet or rheumatic fever, polio.

Adult Illnesses:

- Colitis, ? date.

- CVD; HIN and atrial fibrillation x 5-6 years.

- Osteoarthritis, DJD x 10 yrs.

- Macular degeneration and glaucoma B/L, ? date.

- Hx of fragile skin evidenced by easy bruising and bleeding of arms since youth.

- Lesions L shoulder, upper back, face, scalp treated 2/93 with Bactroban/Ken 1% cream.

- UTI 1 yr ago, resolved after antibiotic.

- Hypothyroidism > 20 years (post-surgical, see operations).

Psychiatric Illnesses: Jan. ’92 – Depression dx, previous hx of depression > 40 years ago.

Accidents and Injuries: See hospitalizations.

Operations:

- Thoracic surgery, 1992 for cancer, no radiation or chemotherapy.

- R knee repair in 1979 and L knee replaced app. 1980 at St. Mary’s Hospital in Rochester, MN.

- Benign tumor L leg app. 10-15 years ago.

- Vaginal hysterectomy, age 46.

- L lacrimal duct, ? reason, > 10 years ago.

- Benign nodule on thyroid, > 20 years ago.

Hospitalizations:

- > 10 years ago, auto accident in Spain, laceration R arm, tx stitches and antibiotic.

- Childbirth x 4.

- Acute neuro dermatitis 5-10 years ago

- Heart fibrillation with SOB, HIN and edema, 5-6 years ago, LOS 3 days.

- Fall with rib contusions, winter 1992, chest x-ray identified shadow, dx lung CA.

Military History: None.

Travel: Frequent travel as a youth – Europe, Great Britain, around U.S. California 1 year ago.

Current Health Status

Allergies: Denies.

Immunizations: Tetanus 10-15 years ago, influenza 11/92, denies hepatitis B, pneumococcal vaccine 11/18/91. Questionable re: pertussis, polio, measles, rubella, diphtheria, or mumps vaccinations.

Screening Tests: Cholesterol WNL 1992, pap smear WNL app. 5-10 years ago, mantoux WNL app. 5-10 years ago, mammogram WNL app. 5 years ago, lower GI series ? date, CXR 1992 identified lung cancer. (Lab per CNS at Dr’s office, summer 1990 TSH 0

.43).

Environmental Hazards: Denies.

Use of Safety Measures: Wears seat belt as passenger. Knowledgeable of EMS, 911, has lifeline in home but doesn’t wear call device. Safety bar in shower, has shower seat but doesn’t use, handrails on staircases.

Exercise and Leisure Activities: Listens to radio or TV, reading (large print), volunteer phone calls to homebound individuals (through C.H.U.M.) Stretching exercises and ROM of large extremities and neck 1-2 x day.

Sleep patterns: See CC.

Nutritional History

Does minimal cooking related to visual deficits and living alone. Has working appliances. Groceries delivered and pays monthly bill. Decreased appetite, misses socialization of eating. Attempted MOW but disliked food. Vegetables cause gas and stomach upset.

Daily Intake: 5-6 glasses water or Tang per day; 1-2 daily servings; 4 grain servings; 1 meat serving; 1-2 fruit/vegetable servings.

Summary: Low protein, high fiber, moderate to high fats, low fruit/vegetable.

Current Medications (per patient)

* = Medications reported by CNS at physician’s office.

Prescribed:

Doxepin 10 mg 1-3 capsules QD, taking 1 q hs (2-16-93)

Bactroban/Ken 1% cream daily

Timoptic* 1 gtt BID each eye

Pilostat* 1 gtt QID each eye

Verelan* 240 mg 1 QD for high BP

Accupril* 10 mg 1 QD high BP

HCTZ* 25 mg 1 QD high BP

Synthroid* 0.125 mg 1 QD

Premarin* 0.625 mg 1 QD

Colace 100 mg 1 1-2x day

Talwin* NX 50 mg, 1 q3-4 hrs pain, uses 1 x week for pain not relieved by Advil.

Advil 200 mg – takes up to 6 per day for pain.

Enteric* coated ASA, 325 mg 1 QD

Diazepam* 2 mg 1 q4-6 hrs prn (client takes with Talwin).

Quinine 325 mg prn leg cramps, uses app. 1x month.

OTC

Throat lozenges (sucrose, starch, etc.), using 4-8 daily for dry mouth.

Vivarin – app. 1 time per week when needing to speed up. Takes in a.m. with lots of water.

Mylanta DS, uses 1 x week for acid stomach.

Phillips MOM tablets – uses if no BM for 3-4 days (app. 1-2 x month)

Multi-vitamin 1 QD (NatureMade brand)

Fibercon QD

Sarina itch lotion

Vani cream

Meds in home (previous usage)

Hydrocortisone cream 1%

Donnatol

Dolobid 250 mg

Anusol cream

Mylicon

Camphophenique (cold sores)

Lactose tablets

Lanacane cream joint pain

Temazepam 15 mg

Robitussin DM

Drawer full of vitamin supplements, too many to review at this time.

Other: Difficulty reading labels, concerned over high cost of meds, meds prescribed by 3-4 different physicians.

Tobacco: Started smoking cigarettes at age 42, quit 10-15 years ago.

Alcohol and Illicit Drugs: Occasional social drinking, primarily bourbon or vodka and OJ app. Every other month.

Family History

Poor historian. Denies knowledge of family history of diabetes, tuberculosis, stroke, kidney disease, epilepsy, mental illness, alcoholism, or drug addiction.

- Children and spouse: 3 children living (1 died age 17 mo., ? cause), 8 healthy grandchildren. Husband died 1975, app. 80 years of age, ? cause.

- Siblings: Sister, died 70s – pneumonia after lung surgery; sister, died 70s – cancer (pancreas and liver); sister, 70s, alive, believes in good health (minimal contact).

- Parents: Mother, died age 82, pneumonia, hx arthritis; Father, died age 71, 2nd heart attack.

- Summary: Positive family history of arthritis, cancer, lung disease (primarily pneumonia), and cardiovascular disease.

Psychosocial and Environmental History

Family was well educated, well established financially, and she traveled frequently in youth and after marriage. Met husband in college, she majored in languages, he was a scientist. Interests included horseback riding, ballroom dancing, pottery, sewing, and outdoor activities. Raised 3 children who now live outside the area. Was active in community theater, volunteer agencies. Husband passed away in 1978, refers to him as Dr., never by first name. Religious affiliation is Unitarian, appreciates liberal philosophy. Believes in freedom of choice, including abortion, and in assisted euthanasia (mentioned Dr. Kavorkian). Unable to attend services related to transportation and embarrassment over visual deficit. Has a living will, oldest son is proxy, doesn’t want life-sustaining medical treatments.

Able to bathe (sponge baths and showers) and dress self without assistance, cooks simple items only. Hires outside assistance for yard and housecleaning. Minimal social activities, rarely leaves home. Contact with family primarily a weekly phone call. Has lived in her two-story 50 y/o home for > 40 years. Home in middle to upper middle class neighborhood, quiet street. Only uses front entrance due to fewer steps. All bedrooms and bathrooms on 2nd level, climbs stairs with use of handrails. No pets, variety of plants. Finished space in basement, which is rented out prn.

Review of Systems

General: Good health, but increased weakness and fatigue x 2 years with 20 lb. weight loss, now 110 lbs. Decrease in height over years of app. 2”, now 5’4”.

Skin: See hx. Xerosis over entire body, uses moisturizing lotions. Easy bruising, thinning or skin and loss of turgor. Denies rash, lumps, change in hair or nails, petechiae, changes in nevi, or changes in pigmentation.

Head and Neck: See neurological for assessment of dizziness. Denies HA or head injury. Denies neck pain, stiffness, tenderness, or masses.

Eyes and Ears: See CC and hx. Eye exam Fall 1992, sees eye Dr. q 6 months. Denies pain, redness, excessive tearing, double vision, or cataracts. Diminished hearing with age, no hearing aide. Hearing in L ear < R. Denies tinnitus, vertigo, earaches, infection, or discharge.

Nose and Sinuses: Sneezes frequently, ? re: house dust. Uses humidifier to moisten air. Occasionally sinus trouble, no intervention except blowing nose in morning resulting in moderate amt. clear discharge. Denies itching, hay fever, or nosebleeds.

Mouth and Throat: Upper plate. Sensation of dryness since surgery in 1992. Denies pain, sore throat, tonsillitis, lesions, hoarseness, dysphagia. Dental exam June 1992.

Breasts: See CC for c/o pain. Denies pain, wheezing, cough, pneumonia, sputum, asthma, bronchitis, emphysema, tuberculosis, pleurisy, hemoptysis, fever or night sweats.

Cardiovascular: See hx. Reports continue problems with HIN and B/P measurement at Drs. Office of 160/100 to 170/110 resulting in adjustments of medications by physician. Occasional edema of lower extremities if sitting for long periods, resolves after raising feet or laying down. ECG prior to surgery in 1992. Denies any palpitations, rheumatic fever, heart murmurs, chest pain or discomfort, dyspnea, orthopnea, paroxysmal nocturnal dyspnea, cyanosis, phlebitis, or claudication.

Gastrointestinal: c/o constipation and “sluggish” BMs. Has BM 3x day, sparse amount of stool, brown in color, medium texture. Using Fibercon and colace daily, 6 glasses of water a day, prunes 3-4 x week. Sensation of thirst since surgery in1992. 20 lb wt loss past 2 years. Decreased appetite re: to living alone and visual deficit. Denies trouble swallowing, heartburn, indigestion, abdominal pain, nausea, vomiting, jaundice, diarrhea, steatorrhea, hematemesis, food intolerance, flatulence or belching, hepatitis, hemorrhoids, liver or gallbladder trouble.

Urinary: Poluria and nocturia which decreased with limiting liquids after 9 p.m. Urine clear yellow, voids in small to moderate amounts. Practices Kegal exercises regularly. Denies burning or pain on urination, hematuria, urgency, reduced caliber or force of urinary stream, hesitancy, incontinence, or stones.

Genital, Female: Regular menstrual periods prior to hysterectomy at age 46. 4 children, vaginal births, 3 spontaneous abortions. Denies discharge, itching, sores, or lumps. Is not sexually active and doesn’t miss sex. On Premarin 0.625 mg QD.

Peripheral Vascular: Occasional leg cramps while in bed, relieved by leg raising, bending, stretching. App. 1x month uses 1 Quinine. Denies varicose veins or clots.

Musculoskeletal: See CC and hx. Generalized muscle weakness, fatigue, and fear of falling are concerns so purposefully slows gait. Denies redness, tenderness to touch, sensation of heat of muscles or joints, limitation of motion, or atrophy.

Neurologic: See CC and hx. Denies paralysis, numbness, tingling, tremors or other involuntary movements.

Hematological: Skin tears and bruises easily with any pressure or friction. Denies anemia, transfusions and reactions, or prolonged bleeding time.

Endocrine/Metabolic: On Synthroid 0.125 mg QD (post-surgical). Gradual weight decline of 20 lbs. Denies intolerance to heat or cold, excessive sweating, diabetes, excessive thirst or hunger, polyuria, changes in hair or skin coloring.

Psychiatric: See CC and hx for dx depression. Believes she is lonely and of little value to society. Reports that CNS at Dr’s office mistook her comments as meaning “suicidal” and she doesn’t agree with this – “I don’t want to take my life, but I have lived too long, I didn’t plan to be 88 years of age.” Reports excellent memory, maintains through use of association and other memory retention techniques. Using meditation and classical music for relaxation.

Occupational: No current employment but does do volunteer phone calls to homebound individuals, spends app. 1 hr. on phone, 3-5 x week.

PHYSICAL EXAMINATION

General: 87 y/o Caucasian female, well groomed, appears younger than stated age. Appears thin, possibly less than stated weight of 110 lbs, small frame. Did not have equipment to assess height or weight. AHR 78 and reg., B/P Alert and cooperative; articulate, chooses words carefully, a deliberate selection of terminology.

Skin: Warm, pink, poor turgor, generally smooth and moist. Thin almost transparent, dominant venous structures. Wrinkled, drooping skin in facial area, neck, arms, and breasts consistent with aging. Dry, flaky skin on upper and lower extremities and back. Baggy appearance under eyes. Ecchymotic area R antecubital 2” in diameter, blush-purple in color. Non-draining lesions with appearance varying from erosion (non-raised loss of superficial epidermis) to raised areas app. 1 mm in height with appearance of a vesicle that has opened. Are .5 – 1cm in diameter, dark pink to light red in color, 4 on R shoulder and upper back, 1 on forehead, 1 on R cheek, 1 on chin. Large scarred area over anterior and proximal region of L shin, which is darker red than the surrounding tissue and feels firmer to touch, non-tender. Well-healed surgical scar of almost crescent shape form below L scapula extending around to app. 9th ICS on side. Well-healed surgical scars on both knees, and well-healed scar app. 5 cm on r forearm. Scar from thyroid surgery only faintly visible in small neck fold. No edema, perspiration, or unusual odor. Fingernails trimmed short, pinkish color with brisk capillary refill, no clubbing; toenails thickened and trimmed short. Thickened skin/ callous present pads of toes, pads of feet and heels.

Head and Neck: Skull symmetrical and smooth, scalp smooth without redness, tenderness, or edema. Whitish gray hair, thin, fine texture. Facial features symmetrical except lacrimal duct and lower lid of L eye is displaced downward (post-surgical area). Neck mobile, full range of motion without tenderness or masses. Trachea midline, thyroid gland not palpable. Sinuses non-tender to palpation and percussion.

Eyes: Reads print of thick black lettering 1” in ht at 6-8 inches with glasses, bright light, and magnifying glass. Visual fields equal examiner, extraocular eye movements intact. Orbital area without edema, conjunctiva pink, no discharge or nystagmus. Iris equal in size, light blue in color. Miosis evident B/L, consistent with use of pilocarpine eye drops, constriction in response to light very minimal but does occur. Able to visualize red light reflex B/L and some vessels but not optic disk.

Ears: Auricles symmetrical, aligned outer eye canthus, no masses or tenderness. Canals non-tender, no discharge, minimal amount of amber cerumen. Tympanic membrane pearly gray in color B/L, all landmarks visible on R and manubrium of L membrane. Diminished response to whispered voice B/L. Unable to hear whisper beyond 6-8” R, 4-6” L. Unable to hear finger rub from either ear at distance of 3-4”. No Weber or Rinne tests (tuning fork unavailable).

Nose: Mucosa pink and moist, no drainage. Nares patent, inferior turbinate pink and equal in size B/L, no polyps. Can identify odor of cinnamon, unable to identify garlic.

Mouth and Throat: Lips pink, symmetrical, without lesions. Wearing upper plate, did not remove for exam at request of client. Gum recession noted lower teeth, no redness, swelling, or tenderness. Teeth ivory in color with some yellowing. Did not count teeth. Tongue symmetrical and midline, extends without tremor. Difficulty opening mouth wide enough for exam of oropharynx, difficult to visualize even with use of tongue blade. Prominent gag reflex. Brief observation revealed uvula that rises with soft palate, not enlarged, unable to visualize tonsils or posterior wall of pharynx. Did not do taste discrimination. Speech is clear, no hesitation, moderate volume.

Chest and Respiratory: Muscle movement and respiratory effort symmetrical, no use of accessory muscles or retractions. AP diameter > lateral. RR 16, lungs clear, no abnormal sounds on auscultation, palpation or percussion.

Breasts: L breast tissue slightly larger than R and tender to touch. No discharge, redness, dimpling, or masses, lymph nodes not palpable.

Cardiac and Peripheral Vascular: Apical impulse not visible, PMI 5th L ICS, mid-clavicular line. AHR 78 and regular, no pulsations, thrills, heaves or lifts, S1 and S2 loud, clear, and of equal intensity without split. No murmur, click, or S3 or S4 auscultated. Assessment on 2/19: 200/98 R arm sitting, radial pulse 78 and 2+, 180/100 standing, radial pulse = 76 but weaker, 1+. Assessment on 2/25: 172/92 R sitting, P = 76, regular; 198/100 R sitting after stair climbing, P = 78, regular. Peripheral pulses: carotid, brachial, and radial pulses 2+ B/L; popliteal, tibial, and pedal pulses 1+ B/L. No jugular venous distension; carotid, temporal, renal arteries, and abdominal aorta without bruits. No edema, swelling or cyanosis. Lower extremities without tenderness, negative Homan’s.

Abdomen: Scaphoid abdomen when supine, skin loose, symmetrical, centrally placed umbilicus; no visible pulsations, peristalsis, or lesions. BS + all quadrants at 26/min. Tympanic sounds throughout, no CVA tenderness. Unable to palpate liver or kidneys, no tenderness with palpation.

Female Genitalia and Rectum: Not examined at request of client.

Lymphatic: No lymph nodes palpated in neck, epitrochlear, or axillary regions. No tenderness in these regions.

Musculoskeletal: Upper and lower extremities symmetrical, slight spinal kyphosis. Stands without wavering, steady slow ambulation, no apparent discomfort. Climbs stairs with handrail assist. Proximal and interphalangeal joints enlarged B/L, firm to touch, non-tender, no redness, questionable enlargement of metacarpophalangeal joints. No tenderness in other joints to palpation or during ROM. Strong hand grasp B/L. Full ROM of neck, shoulder, elbow, wrist, hip, knee, and ankle joints, able to perform ROM against gravity and some resistance. Minimal discomfort with movement of R shoulder, doesn’t limit movement.

Neurologic: Alert, oriented x 3. Answers questions appropriately with ideas expressed logically. Excellent recall of past events including the names of individuals involved, less confidence when recalling events of past few weeks (e.g., unsure of the dates that I visited and the number of visits); 0 errors on SPMSQ (Pfeiffer). Talks in great length of past experiences. Difficult to gain straightforward answer to a simple question, will often offer a long, questionably related response.

See previous exam data for cranial nerves I, II, III, IV, VI, VIII, IX, X, XI, and XII. On V – able to clench teeth with firm, symmetrical muscle strength; able to identify pinpoint and touch equally B/L; did not test corneal reflex. On VII – facial features symmetrical with facial expressions; did not assess taste. Gait – see musculoskeletal. Able to identify sharp and dull equally B/L over face, forearms, hands, and feet. Did not assess temperature response. Sterogenosis and graphesthesia intact. Biceps reflexes 2+ B/L. Unable to obtain brachioradial, achilles, patellar, or triceps reflex.

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