Physical Exam of Adult Client

Physical Exam of the Adult Client

A.L. is an 87 year old female patient who just moved into the Terrace. She comes in today, March 17th, for a new patient evaluation. She was recently discharged from VB Psych center where she was admitted due to paranoid behavior. 

DX: Senile dementia, probably of Alzheimer’s Type; depression/anxiety; also diagnosed with mild CHF (diastolic) with recent echo showing EF of 55%, mild tricuspid and pulmonary valve regurgitation. She was started on Namenda, Zoloft, Risperdal and Lasix (no potassium) while in the psych hospital.

CC: States she loves it hear and has no complaints.

PMH: S/P breast cancer with lumpectomy and radiation treatment; remote Left cerebellar infarct; osteoporosis; Vitamin D deficiency

Head CT apparently shows atrophy, central volume loss and microvascular changes.

The patient came to us on Advair but she denies that she has asthma and I see no mention of it in any records that were sent with her.

Patient was here for rehab after a femur fracture several years ago. I spoke to her daughter after seeing the patient and she tells me that the patient actually has broken both femurs in the past couple of years. She has not been on any treatment for osteoporosis; the daughter is not sure why.

Social: Her husband has Alzheimer's and is on hospice; she has 2 daughters and a son in the area, according to the patient; she has never smoked. Per her daughter, Michelle, the son is really not involved in the family.

Meds: 

Lasix 20 mg qd

Namenda XR 14 mg ER qd 

Metoprolol 12.5 mg BID

Calcium 500 mg qd 

Vit D2 50,000 weekly

Advair disk 100 mcg/50 1 puff BID

Zoloft 50 mg qd

ASA 80 mg qd

Risperdal .25mg qd

Just finished Augmentin 500 mg/125 mg TID for UTI?? 6 doses; Lab confirmation is not documented anywhere in her records (states u/a negative)

She is FULL CODE

ROS: 

Gen: denies fever, chills, states she has lost weight last few months

HEENT: denies headache, visual change, states hearing is pretty...