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S: SUBJECTIVE DATA:

NHC35
86 y/o, African American, Female, Widowed x 2
Patient is main informant; part-time sitter is there to verify information to best
knowledge
Chief Complaint (CC):
Patient presents for follow up on previously diagnosed pyelonephritis. Patient states that
she was down, but better now and wants to make sure she doesnt get down again.
Patient has no complaints/symptoms at this visit.
History of present illness (HPI):
Patient presented on 8/4/14 with painful urination, urinary urgency, urinary frequency,
and increased confusion. She was diagnosed with pyelonephritis and prescribed
Bactrim. Patient is at current visit to recheck urine and denies any symptoms associated
with previous illness.
Denies painful urination, pelvic pain, or low back pain
Denies any pain, urgency, or frequency with urination
Patient states she completed medication with no problems
Denies any other symptoms at this time
Past Medical History (PMH):
Medications:
Aricept
10mg tablet, take 1 tab po qday in the evening
Start date: 8/5/14
Namenda XR
28mg, take 1 capsule po q day
Start date: 8/5/14
Bactrim
800-160mg, take 1 tab po bid for 7 days
Start date: 8/4/14
Allergies: No known drug allergies
Prior illnesses and injuries:
1. Alzheimers, unknown date of onset/diagnosis, currently takes two medications
2. previous diagnosis of hypertension with no current treatment other than
lifestyle modifications and stable blood pressures over last few visits
Surgery History: no known previous surgeries
Previous hospitalizations, treatments and outcomes: no known previous hospitalizations
Immunization (vaccines), colonoscopy, pap smears, mammograms, etc.:
1. unknown immunization status, patient informed and encouraged of influenza
vaccine availability in clinic, unknown screening history- patient is new to clinic
and in process of gathering previous medical history/charts and establishing
health promotion tasks
Family History (FH):
Parents-unknown age, illness, age at death, or cause of death, patient and
caregiver unable to provide this data due to Alzheimers and new caregiver

Patient has no siblings; reported a cousin who lives in Chicago- unknown age or
health status
Patient has no biological children; reports step-children which she has no contact

Social History (SH):


Widowed x 2, states she had two and not getting another one
Lives in apartment building that she owns; the apartment manager (male) lives
in apartment with her and provides care; patient also has female caregiver that
takes her to appointments or to run errands during the day
Retired from Post Office
Reports driving motorcycle all of her life and currently; caregiver states that
motorcycle is torn up and parked in shed now
Denies use of drugs, alcohol or tobacco
Patient states she dropped out of school at the age of 12, moved to Chicago, and
started working for the US Post Office
Unknown sexually history, reports no current sexual activity
Review of Systems (ROS):
(1) constitutional symptoms: denies fatigue or fever; denies recent weight changes;
denies any dizziness
(2) eyes:denies any visual changes or eye problems; unknown last eye exam
(3) ears, nose, mouth and throat: denies ear pain, tinnitus, or hearing loss; denies
discharge and sinus tenderness; denies any dental pain, unknown last dental exam;
denies throat pain
(4) cardiovascular: denies chest pain or palpitations; previously diagnosed with HTN- no
current treatment
5) respiratory: denies shortness of breath , coughing, or wheezing; denies exposure to
TB unknown if previous Mantoux test ; denies hemoptysis or night sweats
(6) gastrointestinal: denies current nausea, vomiting, diarrhea, or gastrointestinal
reflux; reports normal, daily bowel movements
(7) genitourinary: denies any dysuria, pelvic pain, urinary urgency, frequency, or
abnormal bleeding; denies urinary incontinence
(8) musculoskeletal: denies any joint pain, neck pain, or back pain
(9) integument (skin and/or breast): denies any changes in skin, rashes, hair loss, or
bruises; unknown last breast exam/mammogram
(10) neurological: denies severe headaches, numbness, tingling, weakness, or dizziness
(11) psychiatric: denies mood changes, depression, anxiety, nervousness, or insomnia
(12) endocrine: denies cold/heat intolerance, weight changes, or polydipsia, polyphagia,
and polyuria
(13) hematological/lymphatic: denies fatigue and history of anemia
(14) allergic/immunologic: denies any allergies or immunologic compromises

O: OBJECTIVE DATA: (information you observe with your senses, lab results,
and/or chart notes)
(1) Constitutional:), alert and oriented x2 (person and place); appears to be in no
distress; well-nourished and appropriately developed; normal gait and posture. BP:
138/78, RR: 16, Temp 98.3, HR: 68, HT: 56, WT: 113
(2) Eyes: conjunctiva normal, sclera white, PERLA, eye lids normal with no exudate
present
(3) ENT/mouth: grey tympanic membranes with no bulging or cerumen present; nasal
turbinates without drainage or congestion; uvula and tongue midline without tonsil
hypertrophy, erythema, or edema of the mouth or throat.
(4) Cardiovascular: regular rate and rhythm, with no murmurs, rubs, or gallops; bilateral
2+ pulses at radial and dorsalis pedis pulses; all four extremities warm with no edema
(5) Respiratory: clear to auscultation bilaterally and normal respiratory effort; chest wall
is normal, symmetric, and without use of accessory muscles in breathing; chest is nontender upon palpation
(6) GI: normal bowel sounds in all four quadrants; no tenderness or masses upon
palpation
(7) GU: upon palpation bladder was not distended; negative CVA tenderness; denied
vaginal pain/discharge therefore no vaginal exam was performed
(8) Musculoskeletal: normal tone and 5/5 strength with upper and lower extremities; gait
within normal limits
(9) Skin: integument appeared warm, dry, and intact with no rashes, lesions, or
changing moles noted on exam
(10) Neurological: oriented to place and person; eye movements are normal;
communication within normal limits, attention normal with normal concentration ability
(11) Psychiatric: mood and affect are normal
(12) Hematological/lymphatic/immunologic: lymph nodes were not palpated during the
exam and no bruising or discoloration was noted on exam

Labs/Diagnostic Tests
Urinalysis (81003)- positive for WBCs, protein, and blood
Patient previously had CBC, CMP, and lipid panel labs at last visit on 8/4/14.

A: ASSESSMENT / ANALYSIS:
Level 4, established 99214
(599.0) Urinary tract infection - diagnosis given in clinic, further broken down into
following diagnoses:
1. (595) Cystitis (lower UTI)
Positives: patient is elderly and asymptomatic, positive urinalysis results
Negatives: denies dysuria, frequency, pelvic discomfort, or incontinence
2. (590.1) Pyelonephritis (upper UTI)- previously diagnosed 4 weeks prior and
treated for pyelonephritis, patient presented on 8/4/14 with altered mental status,
dysuria, urgency, and frequency; at the current follow-up visit the patient denies
any of these symptoms and the mental status is within normal limits
Positives: hematuria on urinalysis, previous diagnosis, limitation of ADLs due to
Alzheimers
Negatives: denies fever, flank pain, dysuria, urgency or frequency; negative CVA
tenderness

3. (331.0) Alzheimer's - previously diagnosed and currently being treated, has


shown improvement with current treatment as evidenced by compliance with
caregiver and increased social ability
Positives: female gender, age over 85 y/o, inability to retain new information/
recent memory, impairment in executive function, attention, and changes in
personality- agitation and compulsive behaviors

Acute self-limited problems


o Cystitis, UTI- different antibiotic prescribed, patient educated to complete
medication, and to follow up if any symptoms present or worsen
Chronic health problems
o Alzheimers- patient previously diagnosed and prescribed medication,
patient will need to have caregiver to ensure ADLs, needs, and safety is
met for patient, patient will need to return for follow-up appointments with
this diagnosis to ensure medications are providing intended results and no
further implementations need to be made for patient
Health maintenance
o Medication compliance- ensuring to take antibiotic until completion as
directed to prevent relapse or antibiotic resistance, as well as taking both
Alzheimers medications daily as directed to discourage the progression of
the disease and to maintain optimal function and memory
o Hygiene- ensure patient is wiping front to back, avoid douching, and wear
dry, clean, cotton underwear to prevent future UTIs
o Safety concerns- wandering away from home, operating a motor vehicle,
ensure someone is available to assist with ADLs
o Importance of follow-up visits for both future complications with UTIs or
relapses, and with monitoring of Alzheimers disease and medication
regulation

P: PLAN / INTERVENTION / MANAGMENT


1. Cystitis/UTI- prescribed Ciproflaxacin
a. Treatment of UTI, acute cystitis in females
b. Inhibits DNA-gyrase in susceptible organisms, inhibits relaxation of
supercoiled DNA and promotes breakage of double-stranded DNA
c. 250mg every 12 hours for 3 days, or 500mg every 12 hours for 7 days
d. Brand name: Cipro, generic name: ciprofloxacin
e. Walmart: $4
f. Winn Dixie: Free (in generic form per discount list on website)
g. Publix: Free (in generic form per discount list on website)
2. Alzhiemers:- prescribed Aricept and Namenda
Other interventions to include:
No outside diagnostic test or procedures ordered at this time, if UTI
persists or relapses urine culture and sensitivity may be indicated
Follow-up: patient to follow up in 1 month for recheck of urinary diagnosis
and to monitor Alzheimers progression and medication , patient will

continue to have follow up appointments based on patient needs and


progression
Consultation/Referrals- no current consultation or referral needed at this
time
Patient education needs: medication compliance, reporting any symptoms that occur,
personal hygiene, safety, ADLs
Current treatment plan: medication compliance with Aricept and Namenda daily;
adherence and completion of Ciprofloxacin- report any side effects such as yeast
infection/vaginal itching or discharge
Health promotion: personal hygiene, ensuring safety is provided for the patient
and prevention of wandering or operating motor vehicle, assistance with ADLs as
needed, receive influenza and pneumonia vaccinations, schedule screenings such
as colonoscopy, mammogram, eye exam, and dental exam
Health maintenance: medication compliance for UTI and Alzheimers, caregiver
assistance to ensure needs are met, hygiene is maintained, and a safe
environment is established
Disease prevention: low sodium diet, exercise to prevent hypertension that
warrants treatment, ensure adequate hydration to prevent further urinary
diseases
Intervention

Diagnostic Tests:
Urinalysis; positive for WBCs, protein, and blood
Medication:
Ciprofloxacin 500mg; take 1 tab po bid x 5 days for Cystitis/UTI
Aricept 10mg; take 1 tab po q day in evening for Alzheimers
Namenda XR 28mg; take 1 cap po q day for Alzheimers
Education:
Medication compliance, low sodium diet, exercise, safety concerns,
immunizations such as influenza and pneumonia, health promotion
and prevention screenings such as dental, eye, breast, and
colonoscopy
Consultation:
Referral for mammogram and colonoscopy
Dentist and Ophthalmologist
If urinary symptoms persist- referral to Urologist may be needed

Evaluation
Patient is to return to clinic if symptoms persist or worsen. Patient is also to return to
clinic in one month for a follow up urinalysis and medication evaluation for Alzheimers.