Complete Assessment of Mr. Smith
Jackie McManus
University of Missouri Saint Louis

Biographical Data Thomas Smith is a 95-year-old Caucasian male who resides in Saint Charles Missouri. He was born in Saint Louis on June 29, 1917. He is currently married to his wife of 71 years. He is retired from appliance sales and general maintenance. He has lived in Saint Charles, Missouri his entire life except for four years when he served in the United States Army during World War II. While he was in the Army he served in Germany, this was the only time Mr. Smith has been outside the United States.
Source and Reliability Mr. Smith and his daughter Lynn are my source of information to complete my assessment. Lynn has been a nurse for 40 years and is his durable power of attorney, making any medical decisions. She cares for her parents daily by planning their evening meals and setting out their daily meds.
Reason for Seeking Health Care Mr. Smith is seeking healthcare for follow up due to recent falls at home and increased weakness. He complained of weakness in his legs and states that his legs “give out”. He states that his weakness started a couple days prior to going to the hospital and gradually got worse. He was admitted for observation and test where run to determine a mild stroke.
History
Mr. Smith is in generally good health. He is 6 feet 1 inch and weighs 175 pounds. He is getting stronger and is feeling better after his stroke. He states that he has an allergy to Penicillin, which causes a rash. His daughter states that he is able to take Ancef without any reactions. He currently takes Aricept 10 mg daily, Digoxin 0.125mg daily, Synthroid 100mcg daily, Prevacid 40mg daily and Coumadin with the dose changing based on his INR. He has had chickenpox and measles as a child. He is current on his flu and pneumonia vaccinations. He has been hospitalized previously for bradycardia in which he had a pacemaker surgically placed in 2006. He was also hospitalized in the 1980’s for an inguinal hernia repair. His most recent hospitalization was from recent falls where it was discovered that he had a mild stroke. He spent 2 weeks in a rehab facility for strengthening. His daughter also states a history of arthritis, dementia, hearing loss, benign prostatic hyperplasia and skin cancer on his forehead, in which he had outpatient surgery to remove. He also had outpatient surgery to remove cataracts from both eyes in 2010. He currently wears glasses to improve his vision.
Family History Mr. Smith’s family history includes lung cancer, colon cancer, Alzheimer’s and hypertension. His mother died of natural causes. His father died of complications of emphysema. He had one sister that died from colon cancer, one sister that died from a stroke and another that died from Alzheimer’s. He also had five brothers that died from lung cancer. He has one living brother and one living sister. All five brothers that died from lung cancer were all cigarette smokers, while Mr. Smith and his younger brother never smoked. Mr. Smith’s genogram is included on the following page.
Review of Skin, Hair and Nails Skin is warm and dry to touch including hands and feet. Skin is looses and wrinkled with age. Mr. Smith denies any itching or rash. His skin is free of lesions or breakdown other than small bruise noted to left hand, which Mr. Smith states he bumped on table. Skin turgor returns to normal contour in approximately 5 seconds when released. His hair is well maintained. His hair is gray and thinning but evenly distributed. Mr. Smith’s nails of his hands are flat and smooth, with capillary refill retuning within 5 seconds. Nails of his toes are thickened mainly to the bilateral great toes. Nails are trimmed evenly across each toe. Mr. Smith’s daughter states that he has his toenails trimmed several times a year by a podiatrist, which was recently done.
Review of Head, Eyes, Ears, Nose and Sinuses Mr. Smith’s head is round and symmetrical. He denies eye pain, inflammation, or discharge. He wears corrective lenses. His vision tested last year at which time he had a glaucoma test. His daughter states glaucoma test was normal. The sclera of his eyes appears white and moist. The conjunctiva is smooth and pink in both eyes. The pupils are black and round at 3mm bilaterally. Both eyes move smoothly and symmetrically in response to parallel tracking of an ink pen with both eyes. There is evidence of surgical lens implants noted. He states his hearing is good with use of hearing aids. His head is normocephalic with no lumps, lesions, or tenderness. Denies earaches, ear infections, discharge, tinnitus, or vertigo. His daughter states that he has wax build up on his hearing aids and has to have ear wax removed at the physician’s office several times each year. Upon inspection, ear canal has no redness, swelling, tenderness, or drainage. Small amount of cerumen noted to bilateral ears. When whispers test done, he was able to repeat words whispered from a distance of 2 feet. He states his sense of smell has decreased with age. Sinuses intact with No septal deviation or perforation noted. .
Review of Mouth, Throat and Neck
Mr. Smith denies sore throat or mouth. He denies loose teeth or problems chewing or swallowing. He states that his sense of taste has decreased as well as his appetite. His daughter states that he eats “everything you put in front of him”. He denies any bleeding to gums since starting on Coumadin. His mucosa is pink; his tongue is midline, no signs of bleeding to gums. His teeth are dark and yellowing with age. Mr. Smith denies neck pain or swelling. His carotids are palpated 2+ bilaterally with no bruits heard upon auscultation. No masses palpated to neck. Trachea is midline. Neck has limited ROM due to arthritis.
Review of Chest and Respiratory System Mr. Smith denies cough or chest pain with breathing. He states occasional dyspnea on exertion, which resolves with rest. Respirations are relaxed and even at16 times per minute. No signs of accessory muscle use with breathing. Chest has no masses or lumps palpable. Chest expansion is symmetrical. Bronchovesticular breaths sounds heard over below clavicle and between scapulas. Lung sounds clear with mild base crackles present.
Review of Cardiovascular System Mr. Smith denies any chest pain. His heart rhythm is normal at 72 beats per minute. He has no jugular vein distension noted. He has normal S1 and S2 heart sounds with no extra sounds, clicks, gallops or murmurs noted.
Review of Peripheral Vascular System Mr. Smith denies any leg pain or cramping. He states he occasionally has swelling in his feet at the end of the day. Legs have increased redness below the knees with mild 1+ pedal edema noted. No lesions or ulcers noted. Peripheral pulses are palpable with 2+ radial, 1+ pedal and 1+ post-tibial bilaterally. Color change was checked to lower extremities by elevating legs for 30 seconds, then dangling legs with color returning within about 10 seconds.
Review of Gastrointestinal System Abdomen is flat and soft with visible faded scar to right groin from inguinal hernia repair. No rashes or lesions present. Umbilicus is midline with no signs of inflammation or hernia. Abdomen rises and falls evenly with breathing. Bowel sounds ascultated in all 4 quadrants. Abdomen was percussed in all 4 quadrants with tympanic sounds heard over the stomach and dull sounds heard over the kidneys. No organ enlargement, bulges or swelling noted upon palpation of abdomen. No rebound pain or tenderness noted to abdomen. Mr. Smith denies any abdominal pain, nausea or vomiting. States he has bowel movements almost daily and occasionally every other day with his last bowel movement this morning. His daughter states his appetite is good generally eats the same thing on most days, which include an egg and toast for breakfast, a ½ of sandwhich, a ½ of a apple and a Pepsi for lunch. His children bring him and his wife dinner each night, so dinner varies.
Review of Male Genitourinary System Lynn states her father has a history of BPH. Mr. Smith states he has to get up at least once in the middle of the night to urinate. He denies trouble urinating, dribbling or interrupted flow while urinating. His urine is clear, yellow and odorless. He denies every seeing blood in his urine. He denies any pain or lesions to penis, testicles or scrotum. Bladder was palpated with no distension noted.
Review of Sexual Health Mr. Smith denies sexual activity.
Review of Musculoskeletal System Mr. Smith denies muscle pain or weakness. He states arthritic pain in joints of hands and knees, which he takes Tylenol occasionally for the pain. He uses a walker for support while walking and ambulates with a steady gait while using the walker. He is usually able to manage his ADLs and with no physical limitations. His handgrips are strong and equal. His pushes/pulls are strong and equal bilaterally. No evidence of trauma or deformities. He denies tenderness to palpation of joints. No heat, swelling, or masses noted. Joints and muscles are symmetric. Reflexes were tested with a percussion hammer. The response of the bicep reflex was 2+ and the response of the quadriceps reflex was also a 2+. A negative Homans sign and a negative Babinski sign were noted.
Review of Neurological System Mr. Smith is alert and oriented to person, place and date. His speech is clear. He is cooperative. His daughter states that he has dementia with mostly short-term memory affected. He denies any headaches, head injury, dizziness, syncope or seizures. He says he has been feeling great since being released from rehab following his mild stroke. Cerebellar function tested with finger-to-finger test. He was able to touch his finger to mine several times. I also used the finger-to-nose test, which was more difficult. He was only able to touch his nose with his finger when his eyes were open.
Review of Hematological System Mr. Smith has hematology labs done yearly by his primary care physician. His daughter states that his hemoglobin and hematocrit levels have been within normal range. Mr. Smith has recently started having weekly INR blood draws for proper Coumadin dosing. His current INR level is 2.1 at the time of his last lab work. He denies any abnormal bleeding.
Review of Endocrine System Mr. Smith’s daughter states a history of hypothyroidism is which he takes Synthroid. Denies history of family history of Diabetes. Denies any history of pancreatitis. Denies nausea, abdominal pain or malaise. He has yearly blood work by his primary care physician during his routine visits.
Health Promotion Assessment Mr. Smith has been started on Coumadin to prevent clot formation and reduce the risk of another stroke. Although Mr. Smith’s daughter is a nurse, it is important that they be aware of benefits of Coumadin as well as the risk and side effects. I will discuss what Coumadin is, how to take it, the test required to insure proper dosing, as well as side effects and when to call the physician. I will also discuss the effect of Vitamin K with Coumadin and dietary needs to maintain even levels of Vitamin K. I have prepared an educational brochure as a handout, as well as a weekly schedule to record INR results and daily Coumadin doses.

References:
Cleveland Clinic Journal of Medicine. (2003). What you need to know about your warfarin therapy. 70(4), Retrieved March 3, 2013, from http://www.ccjm.org/content/70/4/372.full.pdf
Fiumara, K., & Goldhaber, S. (2009). A patient’s guide to taking coumadin/warfarin. Circulation, 2009(119), 220-222. doi: doi: 10.1161/ CIRCULATIONAHA.108.803957
Important information to know when you are taking: Warfarin (coumadin) and vitamin k. (2012, September 5). Retrieved March 3, 2013, from http://www.cc.nih.gov/ccc/patient_education/drug_nutrient/coumadin1.pdf
Zakhari, R. (2010, January 5). Everything you ever wanted to know about coumadin (warfarin). Retrieved March 3, 2013, from http://metromedicaldirect.wordpress.com/2010/01/05/everything-you-ever-wanted-to-know-about-coumadin-warfarin/