Dementia and Diarrhea Essay

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Clinical History Comprehensive: Nursing Home, dementia, diarrhea DOB: 3-17-13 March 14, 1995 ANNUAL H&P DICTATION – Completed/Dictated 3-9-95 CODE STATUS: DNR/DNI This resident is an 81-year-old gentleman who is pleasant and cooperative but not a good historian due to his dementia. Chief complaint: Resident has been having diarrhea according to his records for the past week, since the 24th of February. He has been having two to three large loose brown stools per day primarily in the evening and at night. He has no nausea, no vomiting, no decrease in appetite, no abdominal pain and no fever. He has some vague complaints of heart burn from time to time, pain in both groins and in both legs. These complaints are…show more content…
He has no siblings and no known relatives. He has never married and has no children. He lived alone all of his life. He served in World War II. He did farm work and worked at a Meat Packing factory. He had a good friend who was quite close to him and looked after him the later years of his life. Resident has a positive outlook on life. REVIEW OF SYSTEMS: A review of systems was attempted but not completed because the resident was unable to concentrate and his answers were not reliable. PHYSICAL EXAM: Height 5’6”. Weight 221 pounds. Weight 1 year ago: 205 pounds. Blood pressure: 130/70. Pulse: 78. (What is the temperature? What is the respiration rate?) Skin: Warm and dry, no rashes, bruises or suspicious lesions, numerous seborrheic keratoses over the back, neck and head. (No skin turgor evaluated due to diarrhea?) Head: Hair thinning, scalp and skull normal. Eyes: Vision good in right eye but very poor in left eye; has corrective lenses but does not wear them. Unable to test EOMs or fields because resident does not cooperate. Red reflex seen in both eyes and vessels appear normal. Discs not visualized. PERRLA, conjunctiva pink, sclera clear. Ears: Drums obscured by wax bilaterally, acuity good to whispered voice. Nose: Mucosa pink, no sinus tenderness. Mouth: Mucosa pink, poor dentition, tongue midline, no lesions on tongue or under tongue or on buccal surfaces, pharynx pink. Neck: trachea
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