A review of his medical records indicates that he had decided to not undergo chemotherapy or radiation therapy for his cancer. He also suffers from chronic stable HTN, Chronic gout and chronic Barrett’s esophagitis and crohn disease. At today's visit he is accompanied by his wife. He is awake, alert and hard of hearing. He reports that he has a poor appetite and not eating much. His wife reports that he has had significant weight loss. She reports that he has not eat lunch or dinner in 7 days. She states that he cough, moan and groan through the nights. He denies having pain. She reports that he has gotten progressively weaker and she is having difficulty care for him by herself. He ambulated with a walker, his gait is unsteady. She reports
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PHYSICAL EXAMINATION: Vital signs are WNL. Apparently he has had no chills, night sweats, or favors. Generalized malaise and a lack of energy have been the main concerns. HEART: Regular rate and rhythm with S1 and S2. No S3 or S4 is heard at this time. LUNGS: Bilateral rhonchi. No significant amphoric sounds are noted. ABDOMON: Soft nontender. No hepatosplenomegaly or masses are detected. RECTAL EXAM: Prostate smooth and firm. No stool is present for hemoccult test.
Physical Examination: General: The patient is an alert, oriented male appearing his stated age. He appears to be in moderate distress. Vital signs: blood pressure 132/78 and pulse 68 and regular. Temperature is 38.56 oC (101.4 oF). HEENT:Normocephalic, atraumatic. Pupils were equal, round, and reactive to light. Ears are clear. Throat is normal. Neck: The neck is supple with no carotid bruits. Lungs: The lungs are clear to auscultation and percussion. Heart: Regular rate and rhythm. Abdomen:Bowel sounds are normal. There is rebound tenderness with maximal discomfort on palpation in the right lower quadrant. Extremities: No clubbing, cyanosis, or edema.
Review of the medical record indicates that he had a MVA in 1977 with C4-5 injury that resulted in him been a Quadriplegic. Due to his bedbound and immobility status he has had multiple pressure ulcers over the years that have resulted in hospital admission and rehab stays. Other medical history include, HTN, hyperlipidemia, Sacral pressure ulcer, Right hip pressure ulcer, Constipation, depression. Bilateral arm contractures, bladder cancer, prostate cancer, urostomy and colostomy, aspiration pneumonia, neuropathy and MRSA.
States that it started 3 days back and uses oxygen at home. States that he is a former smoker and laying on his back feels better. Also says he has a list of medication, more than 20. Pt has a history of COPD, CHF, DM,morbid obesity, HTN, HLM, hypothyroid, and sleep apnea. Has no accessory muscle use. CC is shortness of breath. Assessment is that there is no deformities or trauma of the head or neck area. Chest shows no signs of deformities or trauma. The abdominal area is tender and warm to the touch. Pelvis and back was not assessed. The upper and lower extremities show signs of low circulation and swelling. PMS=4. I helped with placing the BP cuff on the left arm and attaching it to the monitor. First vitals were recorded. O2 was given by the Nurse and then Albuterol by nebulizer. After 30 minutes, I assisted the Nurse and other hospital workers in moving the PT to a bigger bed. Second set of vitals were recorded. After becoming stable the Pt was moved up to the floor.
Pt is a 84 year old Cascasion female living with her husband in their home. Husband reported the Pts Alzhemers has be pergresing for the last 8-9 years. Pt had open heart surgery in 2012, which contributed to the memory loss decline and increasing level of Alzhemer symtoms, husband verbalized. Husband reports they have been married for 19 years. Pt has a sister living Florda, two daughters living in Texas and Wyoming and one son in New York. The children stay in contact with them every other day. Pt reports she worked as a RN at the VA Hospital in New Mexico. Pt is not independent in the home without the husbands assistance. Pt does ambulate well in the home, but does have a walker in needed. Husband assists the Pt all her ADL's in the home and drives her to the store and for MD appointments. Husband currently suffers from Hemochromatosis (too much iron in one's body). Husband reports he manages well with his illness while taking care of Pt at the sametime. Husband reports the Pt's Alzehmers level appears to be stable at this time, but is quite forgetful at times and needs his assistance. Husband said they are managing
As a wife I can understand wanting to take care of your spouse but in some way I feel ,the patient either didn’t understand that her lack of treatment could led to her death . Maybe she didn’t care and made the sacrifice to care for her husband. The care giver role that Mr. Williams is currently in is very common in the elderly especially with spouses. Addressing his anxiety will facilitate a speedier recovery for Mr., and Mrs. Williams.
T.C. went out for testing immediately and unfortunately the test came back that the cancer had aggressively metastasized throughout his body. His pain level increase daily and he became increasingly dependent for all aspects of daily care. Prognosis was for weeks rather then months.
The spouse explained to us that up to two day ago, that patient was able to sit in a wheelchair, ate pureed foods and was awake and alert. What was presented the day in the ER was a patient with multiple fractures, nonverbal and very lethargic. The husband was not aware of any falls, or medical conditions that would cause her symptoms. He also chose not to follow up with exams looking for a reason, such as a stroke. We accepted his wishes and returned his wife back to the nursing home with no treatment. The decision was made as a team effort between the spouse, medical staff, and the patient, with her advance directives.
The clinical features Mrs Lee now 83 is displaying changes to health and cognition noted in the last three to four months, with two transient ischaemic attacks but no significant medical issues. Although currently taking three medications for high blood pressure. Changes in word finding, getting words mixed up and confusing identifying words. Insisting everything is fine showing a lack of insight into her changes or difficulties. Short term memory Mrs Lees has difficulty retaining recent memories, however long term memory appears reasonable. Although Mrs Lees home is reasonably well maintained, she is emaciated and personal hygiene is poor. There is also evidence of emotionally Liable being frequently teary with no reason. History includes
The patient is an 85-year-old female who is brought to the ED by her family because of increasing confusion and supposedly she had a degree of altered mental status of two hours previous to presentation. In the ED she is completely worked up. CT shows advanced atrophy with microvascular changes and several lacunar infarcts nothing acute. Specific gravity in the urine reveals her to be markedly dehydrated. She culture completely, started on IV antibiotics, IV fluids and B12. On the day after admission she still presents as persistently confused. She is evaluated by PT. The patient who was formerly ambulating with a walker and allegedly driving a car is unable to be ambulated. Before the history indicates that she has a slow downward
At today's visit he is awake, alert and oriented. He complains of generalized pain. He states “I have pain all over today, my head, my back, my feet" I have not felt good for the last few days”. He rates his pain as 6/10 in severity; he describes his pain as shooting pain in different places. His pain does
R.H. has a large, active family in the area who assist in his care and plan of treatment as much as possible, and provide daily visits. Prior to the most recent hospital admission, the family reports he was an active man who lived alone, and was quite capable of caring for himself and his house. He has a wife who suffers from dementia and is cared for by their children. He meets with his primary care doctor as well as a home health nurse frequently to monitor his condition and review treatment options. Additionally, the patient is a non-practicing Catholic, with a close group of friends and other support systems within the community. Even with the high level of support he has, the patient is still at an increased risk for ineffective coping due to the sudden onset of his symptoms. Due to his continued weakness and confusion related to high levels of pain medications, much of the decision making is left up to his family, particularly his eldest daughter causing stress for the whole family. Because of his self-care deficit, which will likely extend after discharge, he will likely require extensive rehabilitation as well as being required to live either with family members or in a care facility. The patient and family will need to be continually monitored for ineffective coping for the duration of his hospital stay, as well as following discharge.
His past medical history is pretty benign. He smoked only in his youth probably quit before he was 30 years old. There were no chronic diseases. His past history included an appendectomy, cataract extraction in the distant past. He did see Mike Pike at Cary GI for esophageal problems and apparently had a couple of dilatations of esophageal strictures. He had been followed by the neurology clinic by Dr. Perkins for sleep apnea and used CPAP for the last several years. He does have glaucoma. His most significant past history was that he had some type of a follicular lymphoma treated by Ken Zeitler. He took a pill which apparently put it in remission and took no radiation therapy or chemotherapy. Apparently, he was living very independently in all his ADL's. He drove, took care of all the finances, could complete all his ADL's and instruments of daily living. He was actually still working buying produce at the farmer's market and distributing it and selling it to various restaurants. All this came to an abrupt ending on 10/13, when he presented to the hospital with an acute stroke was there for a week. He had some abnormal liver findings. They thought it might be a recurrence of the lymphoma but these were biopsied and turned
During his old age he suffered from Emphysema and Parkinson’s. Even though he had Emphysema he continued to smoke until the day he died. He refused to take medication because he thought that the side effects would be worse than the illness and it was not worth it. Eventually he lost most of his taste too and everything he ate tasted gross. This caused him to not eat as much as he was supposed to. Also, in the last few years because of the Parkinson’s, he started to have really bad tremors. The worst developed during the last 6 months of his life especially since he refused his