Clinical History

Comprehensive: Nursing Home, dementia, diarrhea

DOB: 3-17-13

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.

Chief complaint:

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 …show more content…

Thorax and lungs: Thorax symmetrical, good expansion, lung fields resonant, vesicular breath sounds throughout, no adventitious sounds.
Cardiac: S1 S2 normal, no S3 or S4, systolic murmur heard at apex and left sternal border, no heaves, lifts or thrills.
Breasts: No nipple discharge or lumps.
Peripheral Vascular: Carotid, brachial, radial and femoral pulses strong and regular. Pedal pulses very faint. Mild lower leg edema, no bruits, normal JVP. Extremities warm, no pallor or cyanosis, no varicosities or calf tenderness. Homan’s negative.
Abdomen: Obese and symmetrical, large well-healed midline scar, bowel sounds normal, no masses or tenderness, no hepatosplenomegaly, no CVA tenderness.
Genitalia: No lesions or discharge on penis. Skin on scrotum and on perineal area reddened and tender. Most likely irritated from diarrhea. No testicular masses felt, although exam was limited because of tenderness of the skin of the scrotum. No inguinal hernia.
Rectum: No hemorrhoids, no masses, stool brown, prostate is smooth, firm, no nodules, no unusual tenderness.
Musculoskeletal: Range of motion normal, no joint deformities. Can wheel self in wheelchair. Transfers with Sara lift.
Neurologic: Cranial nerves 2-12 intact. Oriented to person and place. DTRs are equal, motor testing intact 5/5. Diminished sensation in stocking area of both feet. Finger-to-nose cerebellar testing slightly dysmetric with left hand. Babinski toes down-going. Mini-mental – 16/30.