Mr. Luke, age 58 years was admitted to St. Paul’s Hospital with a medical diagnoses of osteoarthritis. He underwent a total left knee replacement (TKR) five days ago. This afternoon after completing physical therapy he complained that his left leg was unusually painful after walking. You complete an H & P collecting the following data: Retired 5 years ago from a job as a mechanic Not very active at home. Height 6’1, Weight 170 Ibs, History of hypertension, constipation last few years (no BM 3 days) Allergic to penicillin, Needs assistance to ambulate with walker, Smokes one pack of cigarettes
Mr. Luke, age 58 years was admitted to St. Paul’s Hospital with a medical diagnoses of osteoarthritis. He underwent a total left knee replacement (TKR) five days ago. This afternoon after completing physical therapy he complained that his left leg was unusually painful after walking.
You complete an H & P collecting the following data:
Retired 5 years ago from a job as a mechanic Not very active at home. Height 6’1, Weight 170 Ibs, History of hypertension, constipation last few years (no BM 3 days) Allergic to penicillin, Needs assistance to ambulate with walker, Smokes one pack of cigarettes per day.
Physical Assessment V.S. 98-60-16 175/90 pulse ox 93%; Eyes PERRLA, Lungs: clear Abdomen: Firm with increased bowel sound, Urine clear, Redness skin 8 cm coccyx 2 cm open area in center; Complaint of pain to left calf 63 Left leg calf circumference measurement is ¾ inch larger than his right leg circumference; His left leg is warmer to the touch than his right leg
Medications: Enoxaparin (Lovenox) Warfin sodium (Coumadin) Nicotine transdermal patch (Nicoderm CQ) Metoprolol (Lopressor) Hydrocodone Lasix Potassium
Laboratory Data WBC 11.4 RBC 3.0 HEMOGLOBIN 9.8 HEMOCRIT 36 L PLATELET 265 SODIUM 136 POTASSIUM 3.1 Glucose 256 A Doppler ultrasound is positive for a deep vein thrombus (DVT) D-dimer 350
1. Organize the data – use the basic needs list
2. Look for data gaps or inconsistencies
3. Compare individual to norms/standards
4. Identify significant clusters of data
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