LM is an 86-year-old female admitted to the emergency department with delirium. Her spouse is with her and verifies that LM adheres to the medications she is currently prescribed

LM is an 86-year-old female admitted to the emergency department with delirium. Her spouse is with her and verifies that LM adheres to the medications she is currently prescribed. She does not self-monitor her BP or heart rate at home.

PMH:

• A Fib diagnosed 1 month ago

• HTN x 10 years

• CKD x 5 years

• Osteoarthritis x 7 years

• GERD x 20 years

Medications: 

• Digoxin 0.25 mg QD

• Metoprolol XL 25mg QD

• Warfarin 3 mg QD

• APAP 650 mg TID

• Omeprazole 20mg QD

• Multivitamin QD

Allergies: NKDA

Social History:

• Married to husband for 57 years

• No smoking, alcohol, limited daily exercise (short walks each morning)

Family History:

None reported

Vitals:                                     Labs:

Wt 113 lbs Ht 5’4”                   Na+ 138          K+ 4.0

BP 101/58, HR 52                   Cl- 99              CO2 27

                                                BUN 33           Cr 1.2

                                                Gluc 109         INR 3.8

                                                Dig 2.4

PE:

Elderly female with altered level of consciousness, no signs of bruising, bleeding, or other injury.