Health Screening and History of Older Adult

2161 WordsAug 10, 20149 Pages
Health Screening and History of an Older Adult Kimberly Owens Grand Canyon University: NRS 434V (0102) June 28, 2014 Health Screening and History of an Older Adult Biographical Data Client Initials J.H. Age: 78 years old Sex: Male Occupation: Retired Professor Health History and Review of Systems Past Medical history includes : Essential Hypertension, Cardiac pacemaker, Coronary Artery Disease, Dyspnea, Sensiosenural hearing loss, Restless legs, headache, acute hypothyroidism due to radiation, Mandible Cancer, Pseudophakia of both eyes, Posterior vitreous detachment, malnutrition, Generalized weakness, Smoker of 2 packs of cigarettes per day for 30 years. J.H. s is a 78 y.o. male with a history…show more content…
J.H. s is a 78 y.o. male with a history of moderately differentiated SCC of the left mandible. This was diagnosed in October 2013. There was some delay on the patient’s behalf on scheduling the surgery. He then had a sync opal episode and was found to have severe bradycardia and junctional bradycardia. He underwent a CABG X4 for 3 vessel disease and pacemaker placement on 11/10/2013. He underwent a left marginal mandibulectomy and left neck dissections of level 1-4 on 01/23/2014. Pathology reported grade 2 moderately differentiated SCC nodes were positive. Patient declined adjuvant therapy. Patient did well until June when he developed an infection in the hardware. He was taken back to surgery 02/10/2014 for removal of hardware and biopsy of the left cheek and mass, which was found to be invasive cancer. He then agreed to radiation and chemotherapy, which has since started. Since he develop issues with dysphagia during therapy, and a peg tube placement was recommended. He underwent a successful placement of a peg tube on 4/05/14. Physical Examination BP 166/73 | Pulse 69 | Temp 96.9 °F (oral) | Resp 14 | SpO2 99% on room air General appearance: alert and oriented x 3, cooperative, no distress Head: Normal Eyes: Cataract surgery 5 years ago; slightly red Nose: Normal Ears: Hearing is abnormal, currently having to repeat questions
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