Stella B is an 81 year patient of the Northcity Family Practice Group, brought in to the clinic for a general physical examination six weeks ago and seen bi-weekly since then for management of her hypertensive disease. Today Stella is brought in by her daughter-in-law, as she has been on the past three occasions. When taking her blood pressure, the nurse noted bruising in both her arms, a substantial bruise on one side of her face, and some pain in transition from sitting to standing. Stella seemed to be in pain when stood up from the chair in the examination room. Stella states she had fallen the day prior to the clinic visit, though she has not proved to be a good historian and the bruises appear several days old. Stella also indicated that she thought being overmedicated might be part of the problem. Her physical exam shows Stella to be moderately hypertensive (BP 145/90) with a regime of hydrochlorothiazide and Aldomet, mild bladder prolapse with occasional stress incontinence and mild diabetes mellitus controlled with oral medication. Her body weight of 94 lbs with a height of 5'3'' is not unusual for her age. Cognitively Stella is modestly impaired. She has a vague idea who the current president is ("His Dad was President and didn't like broccoli…"), she knows what month of the year it is but not the year, and not the day of the week. She was unable to count backward from 7 past 93. Stella can name her three children, but only 4 of her 8 grandchildren and cannot name her current address.

Social Hx.

Most of the information on this social history was obtained via joint interview with Stella and her daughter-in-law, Doris Frake. Stella is the third child of Polish immigrants, and the only survivor. Her sibling both passed away in the last five years, causes unknown beyond Stella's explanation of "heart trouble". Stella has three living children, two of whom continue to reside in Berwyn, Illinois. Stella was widowed 4 years ago, when her husband died of a massive stroke. Until 2 months ago, Stella was residing in a retirement home in Berwyn. According to Doris Frake, Stella had all but stopped coming down for her meals and was found by the housekeeper in as state of confusion which was attributed to a UTI with some possibility of a contributory TIA. Doris Frake husband, Barney, arranged with his siblings to have Stella visit Seattle for a few months to try to get things straightened out -and Doris now states that Barney feels his mother is too frail to return to the retirement home and feels that Stella should stay in their home on a permanent basis. This plan is apparently supported by Stella's other two children. Although Barney works nights as a school janitor, Doris retired several years ago due to her own health problems and can be with Stella. Doris and Barney's two children have not lived at home for several years, and Stella has a bedroom to herself. Financially, Stella has approximately $1200 per month in Social Security and her husband's pension income. Stella's home in Berwyn, Ill. was transferred to the ownership of her children a couple of years after the death of her husband, and according to Doris there is no other income or savings.

Assessment:

The situation with Stella's current living situation seems to be working, though Doris states that Stella does little for herself and often complains about the food, the house being to hot or too cold, and that her children aren't considerate of her. Doris states that this is not recent, and that Stella has always been sort of a negative person. In presentation Stella seems like a depressed, chronically unhappy person with little to live for in her life. We can certainly manage her hypertension, though her recent falls are a concern and it is entirely possible that this is either attention getting behavior or even syncope. Anti-depressants are a consideration, but at this point I would prefer to monitor the situation with her falls and anti-depressants are unlikely to alter what I suspect is a personality trait.

Dictated by Melissa Tort, M.D.