90 year old woman
Jump to navigation
Jump to search
History
- History of present illness:
- RS is a 90 year old woman admitted to a skilled nursing facility (SNF) in Jan 1997
- She has been referred to hospice for end-stage dementia
- She speaks only a few words, is incontinent of bowel & bladder, is unable to transfer, & appears to have difficulty holding her head up
- This morning she was found dyspneic & tachycardic after an episode of aspiration
- Respirations were 36/min, heart rate > 100/min, & pulse oximetery showed an oxygen saturation of 82% on room air.
- Suction, oxygen by face mask (6 L/min) & 10 mg of morphine sulfate (IM) diminished respirations to 26/min with an oxygen saturation of 92%.
*
- Advance directives have been established.
- She has the 'do not rescusitate', 'do not hospitalize' code status.
*
- Past Medical History:
- Dementia, severe.
- dementia assessed as mild in 4 years prior at the time of admission to SNF
- basic ADLs were 6/6 on admission to nursing home
- she walked with cane on admission to nursing home
- Left lower lobe aspiration pneumonia (3 years prior)
- Urosepsis (3 years prior)
- Coronary artery disease
- Paroxysmal atrial fibrillation
- Congestive heart failure with mitral regurgitation
- Dysphagia
- Depression
- Chronic venous insufficiency
- Hypothyroidism
- Glaucoma
- Vitamin B12 deficiency
- polymyalgia rheumatica
- constipation with hospitalization for bowel obstruction (5 years prior)
- recently treated conjunctivitis
*
- Past Surgical History: cataracts (OD)
*
- Social History:
- Born & lived in Canada prior to 1940
- Moved to Los Angeles in 1940
- Lived in Retrirement Home prior to admission to nursing home
- Admitted to SNF in January of 1997
- Two children, one son & one daughter, both live in Los Angeles
- Daughter AJ is the designated DPOA
*
- Allergies: penicillins, sulfa, erythromycin, cephalosporins
*
- Medications:
- Levoxyl 0.15 mg qd
- Sorbitol 30 mL qd
- Aspirin 81 mg qd
- Colace 100 mg qd
- Timoptic ophthalmic 0.5% bid
Physical examination
- General: quiet, uncooperative, head on chin, no acute distress
- Vitals: T: 99.2 F, P: 82, RR: 26 (unlabored), BP: 150/72
- HEENT: eyes closed, pupils dilated (equally round)
- Lungs: clear to auscultation bilaterally
- CVS: regular rate & rhythm, systolic murmur (apex), no JVD
- Abdomen: soft, non tender, BS+, no organomegaly, no CVA tenderness
- Extremities: trace edema bilaterally
- Skin: moist, good turgor, no mottling
- Neurological: difficult to assess, moves all extremities, DTR 1+
Laboratory
Radiology
- chest x-ray (7 months prior) unremarkable (rule out rib fracture)