Case study form

(Geriatric)
Socio demographic Data:

Patient's name: samieuh Muhammad ali Age: 83 years sex: female

Date of admission:12-3-2017 stay period:7 days

Social statues: widow

Religious: Moslema

Level of education: illiteracy

Occupation before retirement: House wife

Identification of significant others:-

Name: sauda mahmoud Relation with the elderly: her

daughter

Present History
- Diagnosis: pneumonia

- Chief complains of admission: chest pain

- Associated sign and symptom: fever- dyspnea

- Onset \ Duration \ frequency: acute- irregular

- predisposing factors: _________

Past History
Medical

- Diagnosis \ duration: Hypertension / 20 years

- Diagnosis \ duration:Diabetis / 30 years

Surgical
- Name of surgery \ duration: non

- Name of surgery \ duration: non

Allergy history :non

Family history:
- Diagnosis \ Relation:_____
- Diagnosis \ Relation:_____
Accident
-Type \ duration: non

Patient physical assessment

General appearance

Level of consciousness: consciousness

Mobility: depandant

Muscle strength: weakness

Social interactive: Socially

Hygiene: poor

Vital signs

Blood pressure: 160/90 mmhg pulse rate:80 b/m (regular \

irregular) Respiration: 20c/m Temperature: 38.5`c

Height:170cm weight: 130kg

Head & neck

Eyes:

Wearing eye glasses yes ( ) No ( )

Problem of complaint: Loss of near vision

Ears:
 Hearing Normal ( ) Impaired ( )

Problem of complaint :non

Oral cavity:

Lips: Normal yes ( ) No ( )

Teeth

Status: Decay ( ) partial loss ( ) total loss ( )

Dentures: complete ( ) upper ( ) lower ( )

Gums:

Pain ( __ ) bleeding ( __ ) inflamed ( - )

Tongue

Normal ( ) coated ( ) dry ( ) others

Neck

Range of motion:

Pain ( __ ) Distended neck vein ( __ )

Systems Problems Normal Physiological

change
Visual Loss of near vision -loss off at tissue
Loss of central vision around the eye
Loss of peripheral vision may cause the
Glare from lights at night eyelid to droop in
Eye pain very old -The
pupil become
smaller and less
light enters due to
narrowing of the
opening.
-Weakening of
the elasticity of
 ocular muscles.

Auditory Hearing loss -presbycusis is a

Loss of high frequency progressive
range ( presbycussis) bilateral
symmetrical
hearing loss of
high pitched
frequencies that
occurs as a result
of ageing
Cardio- Difficulty eating or -Blood pressure
vascular sleeping increased in both
Over fatigue sexes.
Shortness of breath -valve rigid- thickened
Orthopnea
Pulmonary Chronic cough -Alveoli are
Shortness of breath reduced in
number and
stretched due to a
loss of elasticity.
-The lungs
become rigid and
have less recoil.
-Less lung
expansion.
-The lung exhale
less effectively.

Gastrointestinal Constipation -decrease absorpation

Fecal incontinence
in small intestine
-The function of
usually remains
adequate
throughout life.
-gastric motility
may decrease
resulting in
 delayed emptying
of stomach
contents
Genitourinary Urinary frequency -The bladder
Urinary incontinence capacity
decreases
-Enlargement of
the prostate is
common in older
males, it causes
chronic urinary
retention,
frequency
-The
ureters,bladder
and urethra a lose
muscle tone.
Musculoskeleta Proximal muscle pain \ -high risk for fracture
l weakness -gradual
joint pain progressive
back pain decrease in bone
mass begins after
age of 40years.
-Excessive loss of
bone density
results in
osteoporosis.
-decreased activity and
muscle cramping

integumentary - The
Skin Soft subcutaneous fat
dry decrease on the
wrinkles face, neck, arm,
sagging hand, legs and
Scares feet and increases
Hair Abnormalities on the hips,
 Nails Abnormalities abdomen organs
and muscles.
-in The Hair, The
pigment
decreases, there
by causing it to
gray.
-They grow more
slowly and
become dull and
brittle, and yellow
color, nails
Neurologic\ Transient loss of power -The greatest
psychiatric loss of speech memory deficit is
persistent aphasia or in short-term
dysarthria memory.
disturbance of gait -The inability to
insomnia recall the most
loss of memory recently acquired
information
Extremities Leg and foot swelling -Degenerative
Leg pain joint disease is
found in all older
persons past
age70.
-The muscle
diminish in size
and lose strength,
flexibility, and
endurance with
decreased activity

Weight change Refer to nutrition -Nutrition excess

evaluation below and shortage
have a major role
to play in general
health status.
 C) Cognitive and emotional status

Cognitive status

Orientation to Person ( ) Place ( ) Time ( )

Memory: Recent events ( ) Remote events ( ) both events ( )

Communicate: Able ( ) Difficult ( ) Unable ( )

Emotional status

Normal ( ) problem:

D) Health promotion and prevention practices

Exercise

-Walking: ___ Durian:_____ other:____

Nutrition

Type of diet consumed by the elderly:

Ordinary diet ( )

Therapeutic diet:

Low salt ( ) Diabetic diet ( ) low salt ( )

- Number of meals consumed \ day : 3meals

- Usual amount of fluid intake :1300ml
- food preference specify :
- Eating in group ( ) Eat alone ( )
- Related problem :_____

Rest and sleep :

- Usual sleep and rest pattern :

Day time:4hours At night: 7hours total hours:11 hours

- Sleep disturbance : yes ( ) No ( )

 - Source sleep disturbance: ______
- Medicine used to induce :______

Definition of disease: Is an acute inflammation of the parenchyma

of the lung involving the respiratory broochioles and alveolar sacs

Complication

According to patient According to literature

- Respiratory failure -Bacteremia
- Meningitis
- Respiratory failure
- Lung abscess
- Emphysema

Diagnostic measure

Lab investigation:

According to literature According to patient

Lab investigation Patient's result Normal range Comment
-wBc 12,210^3/UL 4,0-10,0 High
-Rbc 4,3010^3/UL 4.00-6.50 Normal
-HGB 11% 12-16 Low
150-450
-pLt 371 Normal

Radiological examination:

According to literature According to patient

Type of examination Check for what Patient's result
done
chest X-ray un available

un available
 ECG
echocardiography un available

Medical management according to patient

No Drug name Route Dose \ frequency Nursing
precaution
1 clexane S.C 40mg /24 h Monitor pt
and ptt
laboratory
2 capoten oral 25mg/12 h Measuring
blood
pressure
befor
given
medicatio
n
3 Perfalgan I.V 500mg
4 tienam I.V 1 gm Test befor
given
medicatio
n

Medical management according to literature

No Drug name Route Dose \ frequency Side effect if
present
1 antibiotic I.V according to Allergic
patient and by reaction
order doctor
2 oxygen inhalatio according to restlessnes
n patient and by s,
therapy
order doctor difficult
breathing
3 antipyretic I.V according to According
patient and by to type of
 order doctor drug
4 analgesics I.V according to According
patient and by to type of
order doctor drug

E) Risk Behaviors
- Smoking: yes ( ) No ( )

- Caffeine consumption: yes ( ) No ( )

Type: _____ amount \ day: ______

- Others ( specify ): ________