For this Well-Elder Assessment, I interviewed a 72 year old woman, whom I will call M. They both live independently with no outside assistance. This interview took place in her home.
During the interview, I conducted a review of systems with the client. M.M. reported her general health is good with no complaints of weight loss, weakness, fatigue, mood changes, night sweats, or bleeding tendencies. She reported her skin does bruise easily and she does not have dry skin, eczema, psoriasis, acne, changes in pigment, jaundice, itching, or rashes. M.M. reported no mole changes or open sores. She also reports no problem with thinning hair. M.M. has no problems with her finger or toenails.
The client states she has not had a problem with dizziness. M.M. wears prescription glasses and is far-sighted. Her last eye exam was in 2000. M.M. seems to have no loss of hearing and reports no ear problems. The client has dentures on the top and bottom and was not certain when her last dental appointment was. She reports no neck or breast problems. M.M. performs monthly breast self exams and her last mammogram was in 2002. The client's last chest x-ray was in 2001 and it was clear.
M.M. says she has high blood pressure that is treated with medication. The client stated that she does not have varicose veins. She reported that she has occasional constipation and hemorrhoids. M.M. reports no problems with incontinence. She has had no STD's and she started her period at age 13, but is now in menopause.
For her musculoskeletal system, she reports minimal swelling in her fingers, and ankles. She reports minimal soreness and stiffness in her ankles when swollen. M.M. reported no problems with the endocrine system.
As part of this assessment, I performed several tests. The first one was the Folstein's "Mini-Mental State" Questionnaire (Folstein's, 2003). The client scored a 29 on this test, which shows that she is at a decreased risk for dementia.