Mavis Williams is a 72-year-old female with hypertension, gastrosophageal reflux disease (GERD), and Parkinson’s Disease. Ms. Williams was hospitalized three months ago due to a urinary trac
Present Problem Mavis Williams is a 72-year-old female with hypertension, gastrosophageal reflux disease (GERD), and Parkinson’s Disease. Ms. Williams was hospitalized three months ago due to a urinary tract infection and dehydration. She is now a resident of Autumn Acres, a local long-term care facility because her Parkinson’s Disease has progressed, and her son, Michael, can no longer care for her at home. Mavis has lost ten pounds (4.5 kg) in the past month. She is 5 feet-6 inches (167.6 cm), weighs 110 pounds (49.9 kg), and has a BMI of 17.8. After one week of residing at Autumn Acres, Michael visits and is saddened when he finds his mother in her room alone. Michael approaches the nursing station and states, “My mother is so thin and losing weight and sits just staring into space. I thought having her here was going to help her get better!” Personal/Social History Mavis was married to Samuel Williams for 54 years before he passed away two years ago. She has one son, Michael, who lives 30 minutes away. Michael has medical power of attorney for Mavis’s healthcare decisions. Mavis was a homemaker and an active participant in her community. Her hobbies include knitting, playing the piano, and reading. Mavis reluctantly agreed to go to Autumn Acres Long-Term Living Facility after her son accepted a job that required him to travel.
GENERAL SURVEY PAIN NEUROLOGICAL HEAD RESPIRATORY CARDIAC ABDOMEN GENITOURINARY INTEGUMENTARY Alert, flat affect and slow to respond to questions in a soft tone (hypophonia). Oriented and in no acute distress, dress appropriate for the season, hygiene and grooming normal for age and gender. Sitting with a forward-leaning posture. 3/10 ache in knees when she wakes up, but better when she walks. Some mild burning pain on left shoulder. Alert & oriented to person, place, time, and situation (x4); muscle strength 4/5 in both upper and lower extremities bilaterally. Tremors noted at rest in hands, walks leaning forward with short steps Head normocephalic with the symmetry of all facial features, but tremor noted. PERRLA, sclera white bilaterally, conjunctival sac pink bilaterally. Lips, tongue, and oral mucosa pink and tacky dry. Nonlabored respiratory effort on room air. Pink, warm & dry, no edema, heart sounds regular, pulses strong, equal with palpation at radial/pedal/post-tibial landmarks, brisk cap refill. Heart tones are audible and regular, no abnormal beats or murmurs. No JVD noted at 30-45 degrees. Abdomen round, soft, and nontender. BS hypoactive in all four quadrants. Urinary Incontinent episode xl in the last 24 hours, urine vellow Skin oily but warm with normal color. No clubbing of nails, cap refill <3 seconds, Hair soft, distribution normal for age and gender. Skin integrity intact, skin turgor clastic. tenting present.
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