Exam (elaborations)
NURS 5463 Clinical Scenario (REASON FOR CONSULTATION) GRADED A
- Course
- NURS 5463
- Institution
- University Of Texas - Arlington
NURS 5463 Clinical Scenario (REASON FOR CONSULTATION) GRADED A
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Clinical Scenario:REASON FOR CONSULTATION: INR of 4.8
HISTORY OF PRESENT ILLNESS: Mrs. X is a 79-year-old Caucasian female
who accidently slipped and fell today resulting in a left femoral neck fracture
who was admitted to the orthopedic service and will have surgery tomorrow.
She denies any prodrome prior to the fall. She specifically denies any chest
pain, palpitations, shortness of breath, dizziness, syncope, or near syncope
prior to the fall. Of note she hit her head during the fall. The ED completed a
CT of the head and no acute bleeding was noted. A hospitalist consult was
requested because her INR upon evaluation in the ED was 4.8. She has a
history of atrial fibrillation and a mechanical aortic valve. The mechanical
valve is a St. Jude valve which was placed 12 years ago at an outside facility.
She normally takes 3mg of Coumadin daily at home, does not recall her last
INR and states she has been compliant with her medications and diet. Denies
any black or red stools, hematemesis, or hematuria.
Review of Systems:
Constitutional: Negative for diaphoresis, chills, fever, and fatigue.
HENT: Negative for hearing loss, ear pain, nose bleeds, tinnitus.
Eyes:Negative for blurred vision, double vision, photophobia, discharge or
redness.
Respiratory: Negative for hemoptysis, wheezing, cough. Has intermittent
shortness of breath at home.
Cardiovascular: Negative for chest pain, palpitations, orthopnea, leg
swelling or PND.
Gastrointestinal: Negative for heartburn, nausea, vomiting, abdominal
pain, diarrhea, constipation, blood in stool or melena.
Genitourinary: Negative for dysuria, urgency, frequency, hematuria and
flank pain.
Musculoskeletal: Negative for myalgias, back pain and falls. Positive for left
hip pain.
Skin: Negative for itching and rash.
Neurological:Negative for dizziness, tingling, tremors, sensory changes,
speech changes.
Endocrine/hematologic/allergies: Negative for environmental allergies or
polydipsia.
Psychiatric: Negative for depression, hallucinations and memory loss.
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