Imaging Studies
A 78-year-old male presents to the emergency department accompanied by his son. Presents with a 5 day history of dizziness with nausea which worsens with movement, and a sense of fullness in the left ear. Reports the episodes subside quickly if he lays down with eyes closed. Denies vomiting, headaches, shortness of breath, recent falls, or recent infections. Per the client's son, the client has had a decrease in appetite for the past 3 months.
Medical history includes transient ischemic attack (TIA), atrial fibrillation, hypertension, hypercholesterolemia, and gastroesophageal reflux disease (GERD). Client's son informs that the client does not take apixaban as prescribed because he does not like the bruising it causes.
Medications
Carvedilol 12.5 mg by mouth (PO) twice a day (BID)
Apixaban 5 mg by mouth (PO) twice a day (BID)
Atorvastatin 10 mg by mouth (PO) daily, at bedtime
Pantoprazole 40 mg by mouth (PO) daily
Nurses' Notes
0800
Client is laying on a gurney with his eyes closed. Focused assessment completed. Healthcare provider (HCP) arrives. Prescriptions are received
Focused Assessment
Neurological: Alert and oriented, cranial nerve exam II through XII normal. Pupils equal, round, reactive to light and accommodation (PERRLA), Client
reports intermittent tinnitus. Gait unsteady, no motor weakness.
Cardiovascular: Normal rate, irregular rhythm. S1, S2 auscultated with no murmurs.
Respiratory: Lungs clear bilaterally.
Gastrointestinal: Bowel sounds present in all 4 quadrants. Abdomen soft, nondistended, nontender.
Integumentary: Skin intact, thin. Noted multiple bruises on bilateral arms and shins.
Musculoskeletal: 5 out of 5 strength in bilateral upper and lower extremities. No noted paresthesia. Gait unsteady.
0900
Intravenous (IV) access is established in the left antecubital space per prescriptions.
1045
Transported for magnetic resonance imaging (MRI).
Flow Sheet
Orders
Imaging Studies
0900
Urinalysis
Laboratory Test
Result
Reference Range
Appearance
Clear
Clear
Color
Dark yellow
Amber yellow
Odor
Aromatic
Aromatic
5.6
PH
4.6 to 8.0
Protein
3 mg/dL
0 to 8 mg/dL
Specific gravity
1.016
1.005 to 1.030
Leukocyte esterase
Negative
Negative
Ketones
None
None
Bilirubin
None
None
Flow Sheet
Orders
Imaging Studies
0800
Vital signs
Temperature: 97.9ยฐ F (36.6ยฐ C)
Heart rate: 64 beats/minute, irregular
Respirations: 18 breaths/minute
Blood pressure: 172/84 mm Hg
Oxygen saturation: 98% on room air
Pain: rated 0 on a 0 to 10 scale
Height: 5 feet, 10 inches (177.8 cm)
Weight: 136 pounds (61.7 kg)
0945
Vital signs
Temperature: 97.9ยฐ F (36.6ยฐ C)
Heart rate: 68 beats/minute, irregular
Respirations: 17 breaths/minute
Blood pressure: 160/86 mm Hg
Oxygen saturation: 97% on room air
Pain: rated 0 on a 0 to 10 scale