Geriatric History and Physical with Problem List and Plan
Health Assessment Lab
General Patient Information
Client: 81-year-old Caucasian/Italian female
Source: Client, seems reliable
Marital status: Widower
Occupation: House wife
Formal education: High school
Primary language: English, written and spoken
Reason for Seeking Care: Shortness of breath and productive cough.
History of Present Illness: Recurrent episodes of shortness of breathe and productive cough since 2008. First episode occurred when she was in her early 80’s. She was awakened in the middle of the night with a very painful right-sided chest pain and ...view middle of the document...
Her shortness of breath is occurring more frequently with similar onsets as previously described. She keeps her prescribed medication with her at all times.
Respiratory: Other than that reported of shortness of breath and productive cough, no history of on going chest pain. Denies nausea or vomiting. When walking long distances she gets bilateral leg swelling. As mentioned earlier she uses a walker for assistance to prevent her from become short of breath. Occasional wheezes heard on auscultation, bilaterally.
Past Medical History
Childhood illnesses: Chicken pox as young child.
Accidents or Injuries:
2010 Mechanical trip and fall breaking her left wrist and bruising of her face.
Serious or Chronic Illnesses:
2012 diagnosed COPD
2012 diagnosed with Kidney Failure
2008 diagnosed with Congestive Heart Failure
2002 Heart Attack
1999 diagnosed with Hypertension
1996 diagnosed with Diabetes
2013 Kidney Failure / Congestive Heart Failure
2012 Kidney Failure
2012 exacerbation of COPD
2002 Heart attack
Cataracts in both right and left eye
Removal of cancer from left breast
Immunizations: Tetanus / Diphtheria / MMR / Hepatitis B / Influenza / Pneumonia
Last Examination Date:
Last EKG 12/2012
Last physical 9/2011
Last eye exam 6/2010
Allergies: Penicillin / Sulfa / Codeine – No known food allergies
Pantoprazole 40mg once a day
Aspirin 81mg once a day
Furosemide 80mg twice a day
Amiodarone 200mg once a day
Iron 325mg once a day
Cyclobenzatrine 5mg twice a day
Hydralazine 50mg once a day
Vitamin B12 1,000mg once a day
Nitroglycerine 2.5mg twice a day
Simvastatin 40mg once a day
Calcium 600mg once a day
Folic acid 1mg once a day
Potassium Chloride 10mg once a day
Metoprolol 50mg twice a day
Altrazolam 0.5mg once a day
Allopurinol 100mg twice a day
Paternal Grandfather, died age 52 from Heart attack
Paternal Grandmother, died age 86 from old age
Maternal Grandfather, died age 87 from old age
Maternal Grandmother, died age 49 from COPD
Father, died age 83 from Cancer of pancreas
Mother, died age 92 from Heart attack.
Son age 64, alive with history of Cancer / Hypertension
Daughter 57, alive with Multiple Sclerosis / Hypertension / Diverticulitis
Daughter 48, alive with Fibromyalgia
Son [adopted] age 46, alive with Hypertension
Son who passed away at age 6
General: Describes health status as “fair”. Height attained 5’2” weight 183 lbs. Patient states she has not experienced any changes in her weight over the past couple of months. Her ability to do activities has decreased since diagnosed with COPD and Congestive Heart Failure. She notices walking from the car into the house or activities such as watering the garden take more of an effort and her breathing becomes labored. Denies fever, chills, sweats, or night sweats unless exacerbation of...