Name: Phil Gardner Date of Birth: 6/23/19XX Gender: male Age: 78Weight: 162lbs. (73.6 kg) Height: 5’9 Race: Caucasian Religion:Jewish Major Support: Stepdaughter: Sharon Allergies: none knownImmunizations: Current including influenza Attending Provider/Team:Jenna Wong, MD Past Medical History: Diagnosed hypertension at age52. Degenerative arthritis since age 59. History of PresentIllness: Mrs. Gardner is now admitted to a memory care unit at askilled nursing 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. SocialHistory: Mr. Gardner is a78-year-old retired firefighter. Marriedto Lois Gardner since age 51. He lives in an independent home in aretirement community. Lois’s adult daughter from a previousmarriage, Sharon, lives about an hour away. She is a real estateagent 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. Sharonhelps Phil whenever possible. Two couples from their synagoguevisit several times a week and they often bring him home cookedmeals. Phil has two children from a previous marriage, but theyhave demanding jobs and are of limited help to Phil. Mr. Gardeneris on Medicare and supplemental insurance. Primary MedicalDiagnosis: Degenerative arthritis, hypertension. Open-angleglaucoma diagnosed 3 months ago. Surgeries/Procedures & Dates:Left total knee replacement four weeks ago. Medications: Lisinopril20 mg orally every day. Timolol 0.05% + dorzolamide 2% (Cosopt) onedrop in both eyes twice a day. Brimonidine 0.15% solution one dropevery 8 hours in both eyes. Acetaminophen 650 mg oral as neededevery 6 hours for pain: Do not exceed 3000 mg/day.
Person providing report: RN in home care agency. Situation: PhilGardner is a 78-year-old male who is going to physical therapytwice a week following a left total knee replacement four weeksago. Background: Phil was diagnosed with hypertension and was dietcontrolled until recently, at which time he was started on oneantihypertensive agent. He was also recently diagnosed withopen-angle glaucoma and has been prescribed eye drops. Assessment:Mr. Gardner is alert and cooperative. He did not develop signs ofinfection following surgery. His incision is healing well, he iswalking with a cane, but is weaning off the cane to using noassistive device. He reports pain of a 2 or 3 on 0-10 NRS duringtherapy and states it is well managed with occasionalacetaminophen. He drives to therapy and to see his wife, who hasbeen recently admitted to a memory care unit. Recommendation: Philhas recently been started on medications for both hypertension andglaucoma, so it would be important to assess his understanding ofhis treatment plan. Assess his house for safety as he lives alone.Assess his coping skills now that Lois has been admitted to amemory care setting.
Initial Post:
- Identify steps that could have been instituted earlier in thetrajectory of Phil’s care that may have prevented another threemonths of elevated intraocular pressure.
- 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.
