Health Examination Situation- , This Is Mary

Health Examination

Situation-

, this is Mary from the Lake Placid Emergency Room. I am calling about your patient, Mrs. Z, who came in this afternoon complaining of minor vertigo, weakness, and blurry vision, as well as an injured hip.

Mrs. Z is 78 years old, 5' 10" and weighed in at 161 pounds. She is a retired teacher who has lived alone since the death of her husband 2 years ago. Mrs. Z was brought into the clinic by a neighbor, since she gave up driving about a year ago saying she had difficulty seeing in strong sunlight and in the dark.

Mrs. Z was admitted into the ER after a fall that injured her left hip. Our examination reveals mostly unremarkable presentation; this is an informational call to let you know our diagnosis and client recommendations for follow through. We have asked Mrs. Z to make an appointment with you as well, and will be faxing you the results of the tests performed. We believe patient has cataracts and should be immediately seen by an ophthalmologist.

Background-

1. Client came in after falling and injuring her left hip. Client indicated that she was feeding the community cats and did not see the steps as she was walking. Further, she admitted that she might have had several falls both inside and outside the house over the last several months.

2. Client is fairly active, in good psychological health, knows when not to drive. She occasionally self-medicates with 600 mg Ibuprofen for osteo issues. Client does not use tobacco, alcohol, or illicit drugs and presents no emotional or psychological problems.

3. We are not given client's current eyeglass prescription. Her eyesight may be deteriorating, and there are some indications of cataracts: clouded or blurred vision, difficulty with night vision, sensitivity to glare. Falls do not appear to be caused by anything neurologic or cardiological, simply client being unable to see appropriately (Cataracts, 2012).

Assessment

1. Blood pressure is unremarkable, and client reports no unusual symptoms except for falling. All immunizations are up-to-date, and no complications reported from recent surgery. Client presents to be well balanced, with no indication of robust issues. There is no indication of stroke or other neurological issues. (D'Amico & Barbarito, 2011).

Skin, Hair, Nails

No recent abnormalities with exception of client complaint

Head, Neck, related lymphatics

Unremarkable

Eyes

Difficulty seeing in bright or dim light; some perceptual issues

Ears, Nose, Mouth and Throat

Unremarkable

Respiratory Function

Unremarkable

Breasts

Unremarkable

Cardiovascular

Unremarkable; no pain or edema

Peripheral vascular

Unremarkable -- positive pedal pulses

Abdomen

Unremarkable -- no constipation and positive bowel sounds

Urinary

Unremarkable

Musculoskeletal

Some evidence of osteoarthritis in joints of legs, arms and hands.

Neurologic

Unremarkable

2. Radiographs of hip area, as noted, suggest osteo issues, but findings did not include any breaks, hairline fractures, or joint tears. There is some discoloration around the upper thigh area, but this bruising seems to be rather localized and not terribly serious in this instance. Mrs. Z. appears to have sustained a hip pointer based on the swelling, bruising, and tenderness in the area (Brown, 2009).

Recommendation-

1. Part 1 -- For Hip Injury:

a. Rest 48 hours while icing hip area to reduce swelling.

b. Apply ice for 15-20 minutes three to four times a day using a soft towel so skin is not directly iced.

c. Continue with up to 1600 mg/day of Ibuprofen if tolerated, try to take medication with food.

d. Remain hydrated.