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.
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