Resident Mary Jones is an 86-year-old female who fell on the sidewalk, hit her left side including her head, and had a loss of consciousness for about 2 minutes.

Resident Mary Jones is an 86-year-old female who fell on the sidewalk, hit her left side including her head, and had a loss of consciousness for about 2 minutes. She has abrasions on her hands, knees, and left cheek with a laceration about 2 inches above her eyebrow. 911 was called and she was transported to a local hospital. VS: Temp 100.1, Pulse 120, BP 88/56, RR 19, Pain 8/10, weight 70kg.

Past medical history

a-fib, falls, HTN, DM, HLD, osteoporosis, CHF, OSA

Ms. Jones usually walks with a walker and has a steady gait, she knows her limitations. She is alert and oriented X4 and MAE’s with no weakness. Her breath sounds are normal and her HR is irregular with no murmurs. She is on a low salt/2000 carbohydrate diet. She is continent of urine and independent with her ADLSs.

Past surgeries

Hysterectomy 2000

Appendectomy 1995

Current medications:

Warfarin 5mg po QHS

Lasix 40mg PO BID

Metoprolol 25mg po BID

25units NPH insulin SQ QHS

Atorvastatin 40mg po QD

Digoxin 0.25mg PO QD

Multivitamin QD

Potassium chloride 20meq 2 tabs po QD

Torsemide 60mg PO BID

Labs:

CBC

WBC: 11 (RANGE 3.4-10.8)

Rbc: 4.38 (3.77-5.28)

HGB: 5 (11.1-15.9)

HCT: 20 (34-46.6)

MCV: 92 (79-97)

MCH: 33.4 (31.5-35.7)

PLT: 100 (150-450)

CMP:

GLUCOSE: 150 (70-99)

BUN: 26 (6-24)

Creatinine: 2 (0.57-1)

eGFR 95 (59-1.72

Sodium: 140 (134-144)

Potassium 3 (3.5-5.2)

Chloride 99 (96-106)

PT/INR

PT 11.1 (11-13.5)

INR: 2.5 (0.8-1.1)

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