Preview

Dementia and Diarrhea

Powerful Essays
Open Document
Open Document
2098 Words
Grammar
Grammar
Plagiarism
Plagiarism
Writing
Writing
Score
Score
Dementia and Diarrhea
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 very vague and he is unable to elaborate or give any details. The resident feels that his diarrhea is due to eating too many apples. A conversation with the HST caring for him reveals that the resident has been seen very frequently during the past week at the fruit basket in the hall taking and eating fruit.

PAST HISTORY:

Childhood illnesses: Thinks he had the usual childhood illnesses.
Adult illnesses: Diabetes type II diagnosed in 1986, treated with oral hypoglycemics, has peripheral diabetic neuropathy.
Gait disturbance: Began in 1986 after cholecystectomy, multifactorial and related to peripheral neuropathy, wheelchair bound since 1991.
Hypertension: Present before admission in 1992, had hypertensive crisis in January 1994, blood pressure rose to 220/120, presently controlled on Metoprolol.
Cataracts: Bilateral extractions 1986, 1987.
Dementia: Probably Alzheimer’s. In January of 1994 RPR was negative, B12 and folate levels were normal.
Heart murmur: Present at least since admission, grade 2/6.
History of lower extremity edema due to venous insufficiency. A two-dimensional ECHO in January 1994 showed normal left ventricle. Lasix was discontinued and Ted stockings were ordered.
History of viral gastroenteritis:

You May Also Find These Documents Helpful

  • Satisfactory Essays

    H&P Report

    • 306 Words
    • 2 Pages

    SOCIAL HISTORY: Patient admits to drinking beer on the weekends, some tobacco use, but no illicit drug use. Divorced with 4 children, is a long-haul truck driver. Lives with his fiancé.…

    • 306 Words
    • 2 Pages
    Satisfactory Essays
  • Good Essays

    In this scenario the patient is a 72 year old retired rabbi with mild dementia who is admitted to the hospital for a broken right hip due to a fall at home and is receiving pain medication. After a week of being admitted the patients daughter visits her father and finds him restrained. She also notices a red depressed area over her fathers’ lower back when her father is being assisted to the bathroom and was later informed by the dietary worker about her father receiving a pork cutlet on his dinner tray. The daughter was upset with the care being provided and complained to the physician.…

    • 1028 Words
    • 3 Pages
    Good Essays
  • Better Essays

    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.…

    • 2161 Words
    • 10 Pages
    Better Essays
  • Satisfactory Essays

    Nvq Unit 4222-222

    • 338 Words
    • 2 Pages

    e always seek assistance. thing you try is resollving When a resident is eating and drinking we always keep their dignity and make sure they are comfortable by. Sitting them at the table, if needed we put an apron on them so they don’t ruin their cloths. We give them all a drink in a suitable cup or beaker. If a resident needs assistance with eating and drinking we sit on a chair next to them so they feel comfortable and not intimidated in any way by standing over them.…

    • 338 Words
    • 2 Pages
    Satisfactory Essays
  • Good Essays

    3.2.5 Trisha Knowles

    • 787 Words
    • 4 Pages

    The patient has no family history of heart disease or diabetes, however both her parents are on medication for high blood pressure. Her paternal grandmother died of breast cancer at age 47. Her maternal grandmother suffers from severe osteoporosis and her mother is taking prescription medications to slow bone loss.…

    • 787 Words
    • 4 Pages
    Good Essays
  • Powerful Essays

    Case 8 H&P Gerald Edwards

    • 610 Words
    • 3 Pages

    HISTORY OF PRESENT ILLNESS: This is a 53-year-old black individual a patient of Dr. Shelton, who has had diabetes for at least six months, but he thinks it has been longer than that. He says his last known blood sugar was in the 300’s. He presents in the ER today with a foot ulcer since January of this year. He stated that it started with blisters where he had soaked his feet too long in hot water. He has had no eye examination for two years. There has been no surveillance of chronic complications of diabetes.…

    • 610 Words
    • 3 Pages
    Powerful Essays
  • Satisfactory Essays

    Applied Health Assessment

    • 411 Words
    • 2 Pages

    The patient is a 47 year old, well-nourished male. The head-to-toe assessment was insignificant for any abnormal findings. Mike is healthy, appears his age, and does not take medications on a daily basis. His vision is declining with age, but is easily corrected with prescription glasses. His weight has been consistent for the past several years. His BMI is appropriate for his height, and he tries to eat a balanced diet. Though, overall, he is healthy, Mike could benefit from regular exercise, eating more fruits and vegetables, and smoking cessation.…

    • 411 Words
    • 2 Pages
    Satisfactory Essays
  • Better Essays

    Bruce Vielmetti (October 16, 2012). Milwaukee Journal Sentinel, Nursing home rape case settles mid-trial, Retrieved from http://insurancenewsnet.com/…

    • 1319 Words
    • 4 Pages
    Better Essays
  • Better Essays

    Neurological System (headaches, head injuries, dizziness, convulsions, tremors, weakness, numbness, tingling, difficulty speaking, difficulty swallowing, etc., medications):Patient denies headaches, numbness, tingling, convulsions, tremors, difficulty speaking, or difficulty swallowing. Patient does not take any high risk medications. Has complaints of mild weakness and fatigue. States she fell in her kitchen late one night and bumped her head on the laundry room door. States she did not feel dizzy, just tripped over a kitchen chair with her walker. Patient takes no high risk medications. Called 911 for assistance but refused to go to the hospital for evaluation.…

    • 4489 Words
    • 18 Pages
    Better Essays
  • Satisfactory Essays

    HI i dont know

    • 437 Words
    • 2 Pages

    KH is a 67-year-old African-American man with primary hypertension and diabetes mellitus. He is currently taking an angiotensin-converting enzyme (ACE) inhibitor and following a salt-restricted weight loss diet. He is about 30 pounds over his ideal weight. At his clinic visit his blood pressure is noted to be 150/90. His heart rate is 70 BPM. He has no complaints. His wife brought an automatic blood pressure cuff with her in the hope of learning to take her husband’s blood pressure at home.…

    • 437 Words
    • 2 Pages
    Satisfactory Essays
  • Satisfactory Essays

    Nursing

    • 411 Words
    • 2 Pages

    * Incontinence, urinary r/t hx of dementia, impaired mobility aeb “My dad cannot get to the bathroom in time and will often wet himself.”…

    • 411 Words
    • 2 Pages
    Satisfactory Essays
  • Good Essays

    Case Study: Resident

    • 502 Words
    • 3 Pages

    Prior to his hospitalization resident resided at Brooklyn Adult Care Center Assisted Living located at…

    • 502 Words
    • 3 Pages
    Good Essays
  • Good Essays

    Family History: Grandmother and mother have rheumatoid arthritis and have had surgery. Grandma had a hip replacement and his mother had a knee replacement. Most of his family is overweight but there is no history of diabetes or heart disease.…

    • 1992 Words
    • 8 Pages
    Good Essays
  • Good Essays

    daughter insisted on taking him to the ED for evaluation. After orienting him to the room, call light, bed controls, and lights, you perform your physical assessment. The findings are as follows: he is awake, alert, and oriented (AAO) \3, and he moves all extremities well (MAEW). He is restless, is constantly shifting his position, and complains of (C/O) fatigue. Breath sounds are clear to auscultation (CTA). Heart sounds are clear and crisp, with no murmur or rub noted and with a regular rate and rhythm (RRR). Abdomen is flat, slightly rigid, and very tender to palpation throughout, especially in the RUQ; bowel sounds are present. A sharp inspiratory arrest and exclamation of pain occur with deep palpation of the costal margin in the RUQ (positive Murphy’s sign). He reports light-colored stools for 1 week. The patient voids dark amber urine but denies dysuria. Skin and sclera are jaundiced. Admission vital signs (VS) are 164/100, 132, 26, 36° C, SaO2 96% on 2 L of oxygen by nasal cannula (O2/NC).…

    • 1681 Words
    • 7 Pages
    Good Essays
  • Satisfactory Essays

    metabolic syndrome

    • 468 Words
    • 2 Pages

    METABOLIC SYNDROME LEARNING OBJECTIVES At the end of lecture students should know – Definition of Metabolic Syndrome – Visceral obesity is an indicator of the syndrome and an independent marker for CVD – Current and some potential future treatment options. METABOLIC SYNDROME CONCEPT (Not New) • 1923 - Kylin first to describe the clustering of hypertension, hyperglycemia, hyperuricemia • 1936 - Himsworth first reported Insulin insensitivity in diabetics • 1965 - Yalow and Berson developed insulin assay and correlated insulin levels & glucose lowering effects in resistant and non-resistant individuals METABOLIC SYNDROME CONCEPT • 1988 - Reaven in his Banting lecture at the ADA meeting…

    • 468 Words
    • 2 Pages
    Satisfactory Essays