Mrs. Kell is a frail and thin-appearing, pleasant female with remarkable tremor. She is in no acute distress. She complains of tenderness with palpation at her left greater trochanter, as well as to palpation along her hamstrings. Her gait is wide-based and unsteady.
|Vital signs:||BP: 122/62
Weight: 91 lbs
|HEENT:||She has a hearing loss in the right ear and uses a hearing aid on the left. She has some periodic lateral deviation of the left eye. Sclerae clear; Pupils equal, round reactive to light and accommodation. Head is atraumatic, normocephalic. Pharynx is clear. Tympanic membranes are visible bilaterally; some cerumen is present in the right external auditory meatus. Mucosa is moist. Upper & lower dentures are in place and show appropriate fit. Neck is supple. No lymphadenopathy. No visible jugular venous distention. No audible carotid bruits.|
|Chest:||Lungs are clear to auscultation and percussion bilaterally. No wheezes or crepitations. Heart shows regular rate and rhythm, sounds are normal, audible in all areas. No murmurs.|
|Abdomen:||Soft, nontender, non-distended with normoactive bowel sounds. No organomegaly.|
|Extremities:||No edema. The patient has evidence of a high-frequency resting tremor bilaterally in the upper extremities, with pill-rolling in the fingers, which is more pronounced on the left side. The left upper extremity also shows rigidity. Deep tendon reflexes are bilaterally symmetrical with a +3 in all extremities. No cyanosis present.|
|Neurological:||Patient is oriented X3. Speech is slightly slurred. Cranial nerves II-XII grossly intact. Hearing is grossly impaired. Mini-Mental™ State Exam was 20 of 30. She did indicate that some days she just "didn't feel like herself." Mrs. Kell scored a 9 out of 16 on the Geriatric Depression Scale. Questioning was stopped due to patient's tearfulness.|
Her medications currently include Carbidopa-Levodopa 50/200 three times daily, Levothyroxine sodium 0.05 mg/day, Pergolide Mesylate 2 tablets of 0.05mg twice daily, and Aspirin prn.