History

CC:

Monthly comprehensive H&P

HPI:

This is a 76 year old female with an extensive PMHx who was seen and examined today for her monthly comprehensive exam. Pt was seen out of bed in her wheelchair. She was awake, alert and remained verbally responsive throughout the duration of the encounter. Pt mainly communicated via pointing and head nods. Pt remains agreeable throughout the exam. Pt admits to extreme itchiness on R lateral knee and R medial wrist. She says the itchiness has been going on for a while and is always there. PCA confirms that the pt constantly complains about the itchiness.  Pt also has a history of lower back pain and b/l knee pain due to osteoarthritis, but currently is denying all pain.

Nurse has notified providers that the pt seems to be more anxious lately, but when discussed with the pt she says she feels happy and denies anxious feelings. Pt does admit to not being able to fall and stay asleep because her mind races. 

Pt denies current pain, cough, fever/chills, nausea, changes in bowel habits (confirmed by PCA), nasal congestion, suicidal ideation and loss of appetite.

PMHx:

Present chronic illnesses-

• HLD
• HTN
• OA
• Atherosclerosis/CAD
• Dementia

Past medical illnesses-

• CVA- unknown year

Childhood illnesses-

• Denies

Immunizations-

• Up to date

Screening tests and results-

• Unknown

Past Surgical History-

• Cholecystectomy- 2001
• Cataract extraction- unknown year

Medications-

• Aspirin 81 mg, 1 tab QD for CAD/CVA
• Metoprolol Tartrate 12.5 mg, 1 tab BID for HTN
• Acetaminophen 325 mg, 2 tab Q6H PRN pain

Allergies-

• Ciprofloxacin- unknown reaction

Family History:

• Unknown

Social History:

• H.C. is widowed and is a full-time resident at the Gouverneur SNF. She has 1 son and 2 daughters that are involved in her care.  
• Pt is independent in some ADLs. She can ambulate with assistive device and can transfer on her own. She requires her meals to be set up, but can feed herself. She requires a 1 person assist with bathing, dressing and toileting. 
• Pt is continent of urine and stool. 
• Pt is a retired cashier.
• Pt denies alcohol intake.
• Pt denies smoking cigarettes. 
• Pt denies drinking coffee.
• Pt denies illicit drug use.
• Pt denies recent travel.
• Pt says she eats the food provided to her at the SNF.
• Pt reports getting sparse sleep. Pt has a hard time falling asleep and staying asleep.
• Pt is not sexually active.

Review of Systems:

• General: Denies fever, fatigue, chills, night sweats, weight loss/gain and loss of appetite.
• Skin, hair, nails: Admits to pruritus. Denies discolorations, moles, rashes, changes in hair distribution or texture.
• HEENT: Denies head trauma, vertigo, visual disturbances, ear pain, hearing loss, tinnitus, epistaxis, discharge, congestion, sore throat, bleeding gums, dry eyes, dry mouth and eye pain.
• Neck: Denies localized swelling/lumps, stiffness/decreased ROM
• Pulmonary: Denies cough, dyspnea, wheezing, cyanosis, hemoptysis.
• Cardiovascular: Denies chest pain, edema/swelling of ankles or feet, palpitations.
• Gastrointestinal: Denies abdominal pain, nausea, vomiting, jaundice, diarrhea, constipation, dysphagia, pyrosis, flatulence, eructation, rectal bleeding, hemorrhoids or blood in stool.
• Genitourinary: Denies urinary frequency, nocturia, urgency, flank pain, oliguria, polyuria and incontinence, dysuria and malodorous urine.
• Musculoskeletal: Denies joint pain, arthritis, joint swelling, back pain and muscle pain.
• Nervous system: Denies seizures, headache, loss of consciousness, sensory disturbances, ataxia, loss of strength, change in cognition/mental status/memory.
• Peripheral vascular: Denies intermittent claudication, coldness or trophic changes, varicose veins, peripheral edema, or color changes.
• Hematologic: Denies anemia, easy bruising or bleeding, lymph node enlargement, history of DVT/PE.
• Endocrine: Denies polyuria, polydipsia, polyphagia, heat or cold intolerance, goiter, excessive sweating, or hirsutism.
• Psychiatric: Admits to insomnia and racing thoughts. Denies feelings of helplessness, hopelessness, lack of interest in usual activities, or suicidal ideations, anxiety, obsessive/compulsive disorder.

Physical

General:

• Well developed, well nourished female in NAD. Appears stated age of 76. Neatly groomed, alert and oriented x2 (person and place). 

Vitals:

• BP: 125/75 mm Hg
• R: 19/min, regular rate and rhythm, unlabored
• P: 72 beats per minute, regular rate, rhythm and amplitude 
• SpO2: 96% on room air
• T: 97.8 degrees F (temporal)
• Height: 57 inches Weight: 118 lbs BMI: 25.5

Skin & Head:

• Skin: Warm and moist, good turgor. Dry, rough, thickened skin with areas of erythema and scaling on R lateral knee and R medial wrist.
• Nails: No clubbing, cyanosis, or lesions. Capillary refill < 2 seconds in upper and lower extremities. Toenails trimmed.
• Head: Normocephalic, atraumatic with no evidence of contusions, ecchymoses, hematomas, or lacerations, and nontender to palpation throughout.
• Eyes: Symmetrical OU. EOMS intact, no strabismus, nystagmus, exophthalmos, or ptosis. PERRLA.

Nose/Sinuses:

• Nose: Symmetrical. No masses, lesions, deformities, trauma. No discharge visualized. Nares patent bilaterally. Nasal mucosa is pink and well hydrated. Septum midline without lesions, deformities, injection, or perforation. No foreign bodies.

Mouth/Pharynx:

• Teeth: No obvious caries or missing teeth.
• Tongue: Pink and well papillated. No masses, lesions or deviation. No fasciculations.  
• Oropharynx: Well hydrated. No injection, exudate, masses, lesions or foreign bodies. Tonsils present with no swelling, injection or exudate. Uvula midline, pink with no edema or lesions.

Thorax and Lungs:

• Chest: Respirations unlabored/ no paradoxical respirations or use of accessory muscles noted. Non-tender to palpation throughout. 
• Lungs: Clear to auscultation and percussion bilaterally. No adventitious sounds.

Cardiac Exam:

• Heart: Regular rate and rhythm. S1 and S2 are distinct with no murmurs, S3 or S4. No splitting of S2 or friction rubs appreciated. 

Abdominal Exam:

• Abdomen with flat contour with no scars, striae or pulsations noted. Bowel sounds normoactive in all 4 quadrants with no aortic/renal/iliac or femoral bruits. Non-tender to palpation, soft and nondistended. No guarding or rebound noted. 

Peripheral Vascular System:

• Extremities are warm and without edema. No varicosities or stasis changes. Calves are supple, equal in size, non erythematous and nontender. Pulses are 2+ and symmetric. 

Musculoskeletal: 

• No erythema, warmth or crepitus noted. Non-tender to palpation. Full range of motion. 

Differential Diagnosis:

• Xerosis
• Atopic dermatitis/lichenification
• Fungal rash
• GAD

Assessment: 

•  This is a 76 year old female with an extensive PMHx who was seen and examined today for her monthly comprehensive exam. Pt has complaints of intense pruritus on her R knee and wrist with obvious skin thickness, dryness and erythema on exam. These findings are likely due to xerosis, rather than atopic dermatitis due to the lack of history of atopic dermatitis. Pt also is experiencing insomnia and racing thoughts and requires a psych consult. There are no labs or imaging to review at this point. 

Plan:

• Full code

• Xerosis
  • Ammonium Lactate daily
  • Hydrocortisone 1% cream daily
  • Gentle soaps

• Insomnia/anxiety
  • Psych consult
    • They recommend to tx lower back pain, as they suspect the insomnia is due to pain

• Lower back pain/Osteoarthritis
  • Tylenol 325 mg, 2 tab Q6H PRN pain
  • Lidocaine patch PRN on for 12 hrs, off for 12 hrs
  • Menthol/methyl salicylate external cream 10-15% Q12H

• Hx of onychomycosis
  • Had podiatry appointment 10/22/24
  • RTC in 3 months

• CVA
• CAD
  • Continue Aspirin 81 mg QD

• HLD
  • Simvastatin 20 mg held after normal lipid workup last month
  • Recheck lipids this month

• HTN
  • Continue Metoprolol Tartrate 12.5 mg, 1 tab BID
  • BP monitoring 

• Dementia
  • Supportive care
  • Assistance with ADLs
  • Fall precautions

• Consults
  • Podiatry 10/22/24→ RTC in 3 months
  • Ortho- 10/15/24→ RTC PRN
  • Dental- 2/7/24→ RTC annually