Rebecca Sopelak

Health History
10/03/14
A.

BIOGRAPHICAL INFORMATION
Date: 09/22/2014
Name: R.S.
Age: 93
Gender: Female
Martial Status: Widowed
Race: White
Primary language: English
Source of information: Patient (primary source)
Reliability: Oriented x3, happy, okay memory

B.

REASON(S) FOR SEEKING CARE

Chief concern: Patient claims she came to Bridgewater Retirement Community a
few years after her husband died because she was lonely and her family didnt
trust her at home alone anymore because her memory wasnt the best.

C.

PRESENT HEALTH / HISTORY OF PRESENT ILLNESS

Concern: Loneliness
Onset: After her husband passed
Location: emotional, so not set location in the body
Duration: 2 years
Characteristic symptoms: sadness, lack of social interactions
Associated manifestations: none
Relieving factors: being around other people
Exacerbating factors: staying alone in her house
Treatment: moved into the assisted living section of Bridgewater Retirement
Community
Self-treatment: She moved into a small house in Broadway where her and her
husband had first met after his death hoping that it would help ease the loneliness,
but it only helped a little bit.
Past occurrences: none
Concern: Memory Loss
Onset: 5 years ago
Location: brain
Duration: ongoing
Characteristic symptoms: forgetfulness, had trouble remembering how to get
certain places, short term memory decline
Associated manifestations: lack of social interactions due to her husbands passing,
so she didnt have to remember except for her day-to-day needs
Relieving factors: social interactions help to stimulate her brain
Exacerbating factors: not being around people
Treatment: prescription medications

Self-treatment: reads the newspaper and books daily to keep her brain functioning
to slow the decline of her memory
Past occurrences: none
D.

PAST HEALTH
-General health & last examination date(s) and results
General health: Patient states that she is fine. Has slight hearing loss and cant
remember things well anymore. Mentioned her son recently passed and that it
makes her sad to see pictures of him and know hes not here anymore.
Last Examine: The doctor came to see her last week (September 19, 2014). She
had no complications that she can remember. No labs were ordered.
-Childhood illnesses
The patient claims that she had measles, mumps, chickenpox, and strep throat
growing up. Had strep throat a few times, but doesnt know when she had any of
these illnesses. She denies rubella, pertussis, or rheumatic fever.
-Accidents/Injuries
Patient was in a car accident before she was married (sometime in her twenties).
Had no injuries. Went home after accident.
-Major acute/chronic illnesses
Patient denies having any serious or chronic illnesses
-Hospitalizations
Patient has been hospitalized 4 times. Hospitalized for a few days for an
appendectomy in her twenties. Had two children in her twenties. Was in hospital
for about 2 or 3 days she thinks. Hospitalized at 49 for a hysterectomy. Was in
hospital for about a week.
-Surgeries
Appendectomy in her twenties. Hopsitalized for a week. Hysterectomy at 49,
thinks it has something to do with birth of her children, but doesnt know for sure.
Hospitalized for about a week.
-Psychiatric illnesses
Patient denies any psychiatric illnesses.
-Immunizations
Patient knows she has gotten shots recently, but doesnt know why. Chart states
flu shot, September 2013 and TDAP, January 2010.
-Allergies & significant adverse reactions to food, drugs, other chemicals,
including type of reaction
Patient has no allergies or severe reactions to food, drugs, or other chemicals.
Hasnt had any other reactions that she knows of.
-Current Medications
Patient says she has one cup of coffee every morning with breakfast. She knows
she is taking a medication for high blood pressure and takes a bunch of other
medications, but not sure what they are. She claims I just take what they give
me.

E.

FAMILY HISTORY:
Genogram is handwritten and attached in person

F.

REVIEW OF SYSTEMS (ROS):

GENERAL: Patient says she normally weighs around 130 lbs. Denies recent
weight change that she knows of. Claims her clothes still fit her the same as
they did when she bought them. Has generalized weakness in her legs that
she says is from getting old. Has fatigue and takes frequent naps. Has no
fever that she knows of at this time.
SKIN, HAIR, NAILS: Patient denies rashes, lumps or sores. Skin is dry, but
uses lotion regularly to keep moist. Skin color, hair, and nails havent had any
recent changes that she knows of. Hasnt had any change in color or size of
moles.
HEENT:
Head Patient denies any headaches, head injuries, dizziness, or
lightheadedness.
Eyes Patient says her vision is great. Doesnt wear glasses or contacts.
Cant remember when last eye examination was. Has no pain redness,
excessive tearing, or blurred vision. She claims I dont see spots unless I
look at that there sun (seeing as we were outside for the interview).
Doesnt see specks or flashing lights. Doesnt have glaucoma or cataracts
that she knows of.
Ears Patient is hard of hearing. Says she is deaf in left ear. Wears a
hearing aid in her right ear. Has tinnitus every once and a while, but not
an every day occurrence and doesnt last long. Denies vertigo, earaches,
infection, and discharge.
Nose/Sinuses Patient says she gets a cold at least once a winter. She
currently is getting over a slight cold. She doesnt have nose stuffiness,
but does have a slight runny nose. Her nose isnt itchy. She denies ever
having hay fever. She cant directly recall ever having a nosebleed, but
claims Ive reckon Ive had at least one in my life. She doesnt recall
any sinus troubles.
Neck The patient denies having any swollen glands, goiter, lumps, pain,
or neck stiffness
Breasts The patient claims she has no lumps, pain, discomfort, or nipple
discharge. She didnt know what a self-examination was when I asked her
about it and denied ever doing one when I explained what it was. The
only lactation shes had was when she was breastfeeding her children as
infants, which was 60-70 years ago. Her last mammogram was about 10
years ago by her guess.
Axilla Patient denies having any tenderness or swelling
RESPIRATORY: Patient has cough because getting over a cold that started a
week ago. Hasnt been painful and is just an annoyance. Patient reports no
evidence of sputum with cough. Denies hemoptysis. Has dyspnea when
walking too far for too long, but no wheezing with dyspnea. Patent denies
asthma, wheezing, pleurisy, emphysema, pneumonia, or tuberculosis. Had
bronchitis once when she was younger, but couldnt remember when, how
long, or why it started. Hasnt had a chest x-ray.
CARDIAC: Patient states she has a heart condition but not sure what. Said
that the doctor told her about it so long ago she cant remember. Chart says it
is atrial fibrillation. She knows she has irregular heartbeat. She denies
palpitations with condition or prior to finding out about the condition. She has
high blood pressure. Doesnt know when it started. Knows she is on

medication for it. Has dyspnea with walking long distances for an extended
period of time. Moves at a slow pace and takes breaks to compensate. Patient
denies rheumatic fever, heart murmurs, chest pain, orthopnea, paroxysmal
nocturnal dyspnea, or edema. Has had an ECG but doesnt remember the
results and no result in the chart. Uses no assistive devices.
PERIPHERAL VASCULAR: Patient claims fingers and toes are frequently
cold. Claims that when its cold, fingers will sometimes get red if outside for
a long time without gloves on. Normally fingers and toes dont change color
even if cold. She sometimes has pain in her legs. Normally happens when
moving around too much. Doesnt last long as long as she sits down to rest.
If pain persists, asks for medication. Normally resting will help it to go away.
Patient denies numbness, tingling, discoloration or tenderness of her fingers,
toes, or extremities, thrombophlebitis, ulcers, varicose veins, past history of
clots, or swelling of the calves, legs, or feet.
GASTROINTESTINAL: Patient frequently complains about not liking the
food, but eats most of it. She states normally eats most of her breakfast
because often doesnt like other meals, so eats as much of her breakfast as she
can in case the rest of the food is bad that day. She denies trouble swallowing
or heartburn. She wouldnt discuss bowel movements with me because she
didnt think it was appropriate, so denies stool color and size, black or tarry
stools, hemorrhoids, constipation, diarrhea, or rectal conditions. She denies
abdominal pain, food intolerance, excessive belching or passing gas. Denies
ever having jaundice, liver or gallbladder trouble, or hepatitis.
GENITOURINARY: Patient goes to the bathroom to void at least three times
a day. Not incontinent. Doesnt think she gets up at night to go to the
bathroom, but isnt sure. She denies polyuria, urgency, burning or pain during
urination, hematuria, urinary infection, kidney stones, ureteral colic, and
suprapubic pain.
REPRODUCTIVE:
Menstrual history - She doesnt recall her menarche, frequency or duration
of her periods, amount of bleeding, bleeding between periods or after
intercourse, dysmenorrhea, premenstrual symptoms, or her last menstrual
period. She could only tell me that she knows she had periods and they came
regularly.
Menopause history - Patient started menopause at 49. Started because of
hysterectomy.
Genital Issues She would not discuss genital issues with me because it
is too private a matter and it is not appropriate to be sharing with others,
especially young women.
Obstetric history She had 2 pregnancies that she carried to term. Had no
abortions or pregnancies that didnt get carried to term.
Sexual Concerns Sexual preference is men. Was married for 60+ years.
She wouldnt tell me anything beyond this because she thought it was too
private to share. All she would tell me is that she loved her husband very
much.
NEUROLOGICAL: She denies headaches, dizziness, vertigo, fainting,
blackouts, seizures, paralysis, numbness or loss of sensation, tingling, tremors,
or involuntary movements. Has slight weakness in her legs that occur with
pain in her legs. Doesnt have any attention or speech changes. Had a recent

mood change that she attributes to the loss of her son two months ago. Since
then, she states I cant look at pictures of him without feeling empty because
I dont like seeing him and knowing hes not here anymore. Has a slight
change in orientation, loses track of the days since being at Bridgewater. Has
an impaired memory that started after husbands death 10 years ago and
continued to decline over the years. Reads and takes her medications to slow
the decline. She denies any judgment impairment.
PSYCHIATRIC: Patient denies nervousness, tension, anxiety, or suicide
attempts. She reports mood change due to the loss of her son. She denies
depression, although chart says she has depressive disorder and is on a
prescription for it. Has had a recent memory change because that is why she
came to Bridgewater.
HEMATOLOGIC: Patient denies anemia, although her chart contradicts that.
She claims she bruises and bleeds easily because she claims, I am fragile and
thats what happens to old people. Has no past history of transfusions or
transfusion reactions that she knows of.
METABOLIC (ENDOCRINE): Patient denies thyroid issues. She claims to
get cold easily and doesnt like things to be really hot. She denies excessive
sweating, thirst, or hunger, polyuria, change in glove or shoe size, diabetes,
and hypoglycemia.
MUSCULOSKELETAL: Patient states she has muscle and joint stiffness in
legs (knees) occasionally accompanied with pain. If pain occurs, takes
medicine and puts feet up. She denies arthritis, although her chart states
otherwise. She denies gout, backaches, neck pain, or history of trauma. She
has occasional lower back pain. Lies down to relieve the pain.
G.

FUNCTIONAL ASSESSMENT
-Self-Esteem, Self-Concept: Patient views her body as aging, but thinks
she still looks good. Puts on makeup everyday to get pretty and presentable.
Graduated high school and college. Worked as a cafeteria worker in her kids
elementary school in the DC area and was a homemaker when the kids went off to
college and she retired. Wasnt extremely wealthy, but they lived comfortably.
-Activity/ Exercise: Patient walks hall daily for exercise. Likes to read
books and the newspaper for leisure. Likes to go outside or to the library.
-Sleep/Rest: Gets to bed between 7 and 8pm every night and tends to wake
up around 6:30 am. Takes at least 3 naps a day. Doesnt take any sleep aids.
- Nutrition/Hydration: In a 24 hour period, eats her entire breakfast, about
half of lunch, and about half of dinner. Shes not sure what she eats at each meal,
but knows she has a cup of coffee every morning with breakfast, drinks at least
three glasses of water each day, and has pancakes and fruit for breakfast.
Sometimes shell have eggs for breakfast, but that is all she can remember.
-Role/Relationship: She doesnt really talk to many of the people on her
floor. She likes when her family visits. Her daughter-in-law tries to come every
Sunday. She tries to call her daughter every Monday. If she doesnt call her
daughter, her daughter will normally call her. Three of her seven siblings are still
living, but doesnt get to see them as much as she wants to. She used to see her
son every day when he also lived at Bridgewater.

-Spiritual Resources: She went to church every Sunday before moving to

Bridgewater. Since coming to Bridgewater, she cant really go to church anymore.
The Chaplin comes to visit, but she doesnt go to church every week.
-Coping and Stress Management: She mentioned she got very upset at the
passing of her husband and son. Major stressor in the past year was the death of
her son two months ago. Had her daughter take home the pictures of her son
because she couldnt bare to look at him and know that hes not here anymore.
-Tobacco/Alcohol/Drug use: She denies tobacco, marijuana, cocaine,
crack, amphetamines, heroin, painkillers, and barbiturate use. She doesnt
remember drinking alcohol, but thinks that shes probably had a few drinks over
her lifetime.
-Environmental Hazards/Exposures: She lived in safe neighborhoods with
her family. Moved around a few times in her married life, but most of married life
was spent in suburb outside of DC, Timberville, and Broadway, VA. Lived in nice
houses that had indoor heat and plumbing. Both her and her husband had cars and
always wore their seatbelts. Never took the metro or buses. Job was in cafeteria,
so only work place hazards had were potential burns from the oven and colds from
the kids.
-Violence: Patient states I would never let anyone lay a finger on me.
Denies ever being hit, slapped, kicked, punched, physically hurt, or forced to have
sexual activities.
-Occupational Health: Worked as cafeteria worker and homemaker. No
real health hazards. Hair nets were only protective equipment.
H.

PERCEPTION OF HEALTH, ILLNESS, RISKS, NEED FOR TREATMENT

-Definition of health: Person who is has no sickness, like a cough or cold
-View of her situation: Im here because my family didnt think I was safe at
home and I was lonely. I moved upstairs because my family wanted me too. I
like it here, I just wish I could go outside more.
-What are your concerns: My daughter will be alone when Im gone
-Health Goals: Live the best she can, outlive her siblings
-What do you think will happen in the future?: She didnt want to talk about it
-What do you expect from the nurses, physicians, and health care providers?:
Wants them to be nice to her and take her outside

I.

SUMMARY
From the data, it is evident that the patient does suffer from dementia and
depressive order as stated in her chart. She has her moments of happiness when
talking about the past and reminiscing, but when you switch to questions about
the present; you can see the sadness from loss in her expressions and voice. She
is impressively healthy besides the depression and dementia. She can recall a lot
of information for being 93 years-old and having dementia. She can also move
around and preform all of her ADLs. The older she gets, she is more at risk for
falls. She walks with a walker, which already puts her at risk for falls. For right
now, she needs more visitors. She loves to talk about her family, which tells me
that she misses them greatly. I dont know if they come visit her every day and
she doesnt know it, but she only remembers them coming to see her on Sundays
and talking to her daughter on Mondays. Seeing her family more frequently
could definitely help her cope with the loss of her son by showing her that not all

of her family is gone and she is not alone. My plan for her would be to get her to
interact more with other residents to make her feel less alone. I will also try to
ask her reminiscing questions to keep in her good spirits when Im there. Im
hoping that by providing her with more social interactions, she will regain some
energy, not feel so alone, and help her cope with her sons death.