Question

TR is a 78-year-old female, who weighs 83.2kg (183 lbs. 6oz) and stands 152.4 cm (5 ft.). She states she lives with her spouse of 55 years and both are independent and active. Her code status is DNR and her Physician is Dr. Jon Doe. She states she wears glasses due to an eye injury when she was young and also has hearing aids but left them both of them at home.

Allergies: Ace inhibitors—unknown reaction, Actos—dizziness, throat swelling, Endocet—hives, Penicillin’s –hives, Tomatoes (raw) itching/rash

Past Medical History: per patient and husband: Hypertension, Kidney Infections, Stage III Chronic Kidney Disease, Heart murmur, Aortic stenosis, Congestive Heart Failure, Bronchitis, GERD, GI bleed, Endoscopy (February 2016)

TR states she was feeling “fine” the past 24 hours. She then began to have “flu-like” symptoms: headache, neck /jaw pain, mid-abdominal pain, weak and tired, loose stools, nausea, dizziness, poor balance, and decreased appetite. She was brought to the ER by her spouse, after talking to her FMD. Some blood work was drawn HGB 5.7—2 units of Packed Red Blood Cells ordered, INR 4.3----Vitamin K given. Coumadin put on hold. Gastroenterologists were consulted after blood was detected during a + (positive)Hemoccult test, indicating upper GI bleed. IV fluids were started, and it was decided she would be admitted.

On admission to the Medical-Surgical Unit, TR: She states she has a headache and some neck & jaw pain, mid abdominal pain, loose stools since yesterday, a little nausea that gets better with eating a few crackers, fatigue, dizziness especially after standing up after sitting for a while, poor balance, and decreased appetite. She states she does look a little pale compared to her usual tan self. TR denies vomiting, chest pain, shortness of breath, problems with urination and denies visible bloody stools. The patient was made NPO for further testing and was admitted to a Medical-Surgical/Telemetry unit. Her VS. are T- 99.8F oral, HR 96 and irregular, RR 18, BP 100/58, POX 96% on room air.

Later in the day after receiving the blood transfusion her Hgb was 6.8 HCT was 20.1, and another 2 units of PRBCs were ordered. After the second blood transfusion her repeat Hgb was 10.1, INR 3.1. Small bowel push enteroscopy was ordered. Prior to the test her assessment revealed: she is alert, oriented x3, dressed in a patient gown. Her speech was clear, and she was able to answer questions appropriately, skin slightly pale with delayed turgor, s1 s2 heart sounds, with a murmur noted at the mitral valve, lungs sounds were clear, no adventitious sounds, her lips appeared dry with a few cracks. She used the restroom and her urine was noted to be dark yellow in color and measured 100 mL. TR said “don’t worry about that its always that way”. Abdomen slightly round, symmetrical, hyperactive bowel sounds in all 4 quadrants, soft but slightly tender RUQ and tympanic throughout.

She returned to the unit: Results of her: Schatzki ring (narrowing of lower esophagus), small hiatus hernia (part of stomach pushed up through diaphragm) gastric melanosis (excess melanin) resulting in benign mucosa changes, single bleeding angioectasia (acquired lesion--bleeding) in the duodenum that was clipped with MRI compatible clips. She was able to ambulate to the bed with a slight imbalance and required 1 assist with a Gait belt. She requested examination of her right heel because it was “sore” and bothering her. She also stated her feet often get tingly and numb. Upon inspection it was noted she had a blister on her right heel and her right great toe appeared red and was also sore to the touch. Her pedal pulse was noted to be a +1 on the right and +2 on the left, bilateral sluggish capillary refill. +3 pitting edema in bilateral lower extremities was assessed, to which patient stated, “they get like that sometimes”.   She was started on clear liquids which she consumed 50% without difficulty and stated she continued to feel slightly nauseated. Patient asked if she could have some eye drops because her eyes feel dry. Upon inspection her eyes have no drainage, sclera is noted to be white, and conjunctiva is red and dry in appearance.

Complete a physical assessment on TR using the case study to break the assessment into the following: General Survey, Integumentary, HEENT, Sensory-Neurologic, Cardiovascular, Gastrointestinal, Genitourinary, and Musculoskeletal.

Answer 1

General survey

Name :- Mrs TR

Age:-78 years

Sex :- Female

General appearance :- patient is conscious and oriented.

GCS/LOC:-15/15

Past medical history:-Having chronic diseases like CHF, CKD stage 3, Heart murmur, HTN, Bronchitis, GERD, GI bleed and endoscopy done on feb2016, aortic stenosis.

Present medical history:-flu like symptoms, abdominal pain, headache, jawpain, loosestool, nausea, dizziness, poorbalance and decreased apetite.

Allergic history:-patient having allergic history of ACE inhibitors, Actos, Endocet, pencillin and tomatoes.

State of distress :- patient having no evidence of distress.

Height:- 152.4 CM

Weight:-83.2 KG

Build:- Obese

Gait:- mild imbalance in the gait

Appearance :- obese well built and on hospital gown.

Vitals

HR:- 96beats/min

BP:- 100/58 mm/hg

RR:-18 breath/min

Spo2:- 96%on room air.

Temp:- 99.8°Fn

Integumentary system

Skin colour:- pale

Skin turgour :- delayed

Lips :- having cracks

Bed sore :- No evidence of any bed sore

Heels :- a blister is present in the right heel and it is sore to the touch

Skin integrity :- impaired

Head:- patint having dizziness and head ache

Eyes:- patient have history of eye injury in the young age and using eye glassess.

Eyes are pale and dry

Sclera is normal and white in color and conjuctiva is red and dry in aplearance.

Ears :- patient is on use of hearing aid and it is left home. So patient having poor hearing ability.

Nose :-No relevent symptoms in the nose

Throat:- Having a clear voice and no other complaints in throat

Sensory neurologic

Patient having pain in the abdomen. Neurological status is fine answering all questions. No evidence of disorientation and no other sensory impaired found other than the hearing issue.

Mental status :- normal

Motor function :- normal

Cardiovascular

Heart sounds :- s1 s2 heard

Heart beat:- 96 b/ mt

Capillary refill:- +1 on the right and +2 on the left, B/L sluggish and + 3 pitting edema in lower extrimities

Heart murmer :- present in the mitral valve

Lung sounds :- clear

Other cardinal symptoms :- dizziness, shortness of breath, nausea, fatigue

Gastro intestinal

• Inspection :- on inspection abdomen is round symmetrical and hiatal hernia present in the abdomen.Also signs of scatiz ring and gastric melanosis.
• Ascultation :- On ascultationbowel is hyperactive.
• Palpation:- during palpation RUQ is soft and tender
• Percussion :- abdomen normal and soft. No evidence of fluid collection present

Appetite of the patient is decreased. Having nausea and mild pain. Gl bleed also present.patient having loose stools

Genito urinary:-

Kidneys, :- patient having acute kidney infection and stage 3 CKD.

Problems in urination :- present

Color of urine :- dark yellow,

Frequency :- normal

Amount :- 100 ml.

Muskulo skeletal

Temp :- high than normal

Joints :- weakness present

Pain :-present in the jaw and neck

Swelling :- present in the lower extrimities

Mass:- no visible mass present

Symmetry of joints :- normal

Posture :- weak and tired