Name: PhilGardner
Date of Birth: 6/23/19XX
Gender:male Age:78 Weight: 162lbs. (73.6 kg) Height: 5’9
Race:Caucasian Religion: Jewish
Major Support: Stepdaughter:Sharon
Allergies: noneknown Immunizations: Current including influenza
Attending Provider/Team: Jenna Wong, MD
Past Medical History: Diagnosed hypertension at age 52.Degenerative arthritis since age 59.
History of Present Illness:
Mrs. Gardner is now admitted to a memory care unit at a skillednursing facility. Mr. Gardener had a successful total kneereplacement 4 weeks ago and he is living at home alone. He haspermission to drive his car. He experienced headaches and visualchanges 3 months ago and was diagnosed with glaucoma.
Social History: Mr. Gardner is a78-year-old retired firefighter.Married to Lois Gardner since age 51. He lives in an independenthome in a retirement community. Lois’s adult daughter from aprevious marriage, Sharon, lives about an hour away. She is a realestate agent and single parent to a 16-year-old son, a 14- year-olddaughter and an 8-year-old daughter. She has been diagnosed withchronic back pain following a car accident four years ago
Mr. Gardener is attentive to Lois and visits her regularly.Sharon helps Phil whenever possible. Two couples from theirsynagogue visit several times a week and they often bring him homecooked meals. Phil has two children from a previous marriage, butthey have demanding jobs and are of limited help to Phil. Mr.Gardener is on Medicare and supplemental insurance.
Primary Medical Diagnosis: Degenerative arthritis, hypertension.Open-angle glaucoma diagnosed 3 months ago.
Surgeries/Procedures & Dates: Left total knee replacementfour weeks ago.
Medications:
Lisinopril 20 mg orally every day.
Timolol 0.05% + dorzolamide 2% (Cosopt) one drop in both eyestwice a day.
Brimonidine 0.15% solution one drop every 8 hours in botheyes.
Acetaminophen 650 mg oral as needed every 6 hours for pain: Donot exceed 3000 mg/day.
Person providing report: RN in home careagency.
Situation: Phil Gardner is a 78-year-old malewho is going to physical therapy twice a week following a lefttotal knee replacement four weeks ago.
Background: Phil was diagnosed withhypertension and was diet controlled until recently, at which timehe was started on one antihypertensive agent. He was also recentlydiagnosed with open-angle glaucoma and has been prescribed eyedrops.
Assessment: Mr. Gardner is alert andcooperative. He did not develop signs of infection followingsurgery. His incision is healing well, he is walking with a cane,but is weaning off the cane to using no assistive device. Hereports pain of a 2 or 3 on 0-10 NRS during therapy and states itis well managed with occasional acetaminophen. He drivesto therapy and to see his wife, who has been recently admitted to amemory care unit.
Recommendation: Phil has recently been startedon medications for both hypertension and glaucoma, so it would beimportant to assess his understanding of his treatment plan. Assesshis house for safety as he lives alone. Assess his coping skillsnow that Lois has been admitted to a memory care setting.
Initial Post:
a. Identify steps that could have been instituted earlier in thetrajectory of Phil’s care that may have prevented another threemonths of elevated intraocular pressure.
b. His daughter and grandson have used the internet and theyprovided Mr. Gardner with an incomplete or inaccurate descriptionof his condition. Develop a patient-centered teaching plan for Philincluding information about his eye disease process and treatmentwith ocular medications.
