DAVIS HOSPITAL AND MEDICAL CENTER

Phone Intake COLORS: RED - PAIN ORANGE - AGITATION GREEN - TERMINAL

HISTORY AND PHYSICAL EXAMINATION

PATIENT: Smith, Lydia

Robert F. Bitner, M.D.

Admit: 12-20-95

HISTORY

This is a 90-year-old lady that was admitted yesterday for care. She is very confused and appears to be angry and resentful of anything that is being done here. She is able to walk around and seems to do so without help, although the nurses watch her and help her to move from one place to another. She is a little bit combative at times, she refused to let me do a physical examination other than just observe her general function.

I had no conversation with the family, who I am sure could give me a lot of information about the background. I understand that Dr. Weitzel will obtain information.

PAST HISTORY

I understand she has had some trouble with constipation and occasionally incontinence. She had an accident to her shoulder several years ago in a car accident and has a "frozen shoulder" because of that. She complains of no pain anywhere and no dysfunction but apparently she has been using Tylenol off and on for that.

She is quite restless and somewhat agitated as I approach her and explain who I am and so on. She is totally uncooperative other than to voice some resentment in a kind of garbled fashion that I did not understand.

Her family is interested in her care but apparently not to the point of being able to help or know what to do.

She has been said to have confusion and disorientation and in between times she becomes quite aggressive. I saw her pinching the nurse and kicking at her. I was giving her some very kind help as far as sitting, etc., but she identified anything as very negative. She has apparently been treated with Prozac in the past and is allergic to these things.

Continued….

HISTORY AND PHYSICAL

Lydia Smith

Page 2 . . . HP

Robert F. Bitner, M.D.

The history tells us that she has lost about 30 pound in the past year and there is some question about her appetite.

MEDICAITONS: Have included Haldol 0.5 mg t.i.d., Normodyne 200 mg b.i.d., Lanoxin 0.125 mg daily, potassium and Lasix are also noted. Apparently these medications are used on sort of a p.r.n. basis.

PHYSICAL EXAMINATION

GENERAL: Physically she appears to be frail but is strong enough to get up and walk around, especially with help. She shows evidence of weight loss, she is very thin but in general she is quite functional.

VITAL SIGNS: Blood pressure recorded by the nurse is 130/60 with pulse of 80 that is regular.

HEENT:

NECK:

LUNGS:

HEART:

BREASTS:

ABDOMEN:

PELVIS:

EXTREMITIES:

NEUROLOGICAL: Her mental state is pretty bad.

DIAGNOSIS

Arteriosclerotic cardiovascular disease, especially cerebral arteriosclerosis.