Comprehensive: Nursing Home, dementia, diarrhea
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.
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.
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: