Patient has varicose veins present bilaterally. Pulses: •Popliteal •posterior tibial •dorsalis pedis Popliteal pulse +2 bilaterally, Posterior tibial +2 bilaterally Dorsalis pedis +2 bilaterally Temperature and pretibial edema Lower extremities are warm, Pretibial edema present in right extremity +1, nonpitting. Toes Toes intact, able to move without pain or tenderness. Toenails thick bilaterally, without redness or sores. ROM and Muscle Strength
14 Ankles and feet Full ROM of ankles and feet without pain. +5 leg and feet strength bilaterally Neurologic Alert and orientated to person, place, time and situation. Memory not fully intact struggles with history and words. Sensation: •face •arms •hands •legs •feet not assessed Position sense Not assessed Stereognosis 2/3 objects identified correctly Cerebellar function (finger to nose) Not assessed Cerebellar function (heel to shin) Not assessed Deep tendon reflexes: •biceps •triceps •brachioradialis •patellar •achilles Biceps 2+ bilaterally Triceps 2+ bilaterally Brachioradialis 2+bilaterally Patellar 2+ bilaterally Achilles 2+ bilaterally Babinski reflex Not assessed Musculoskeletal Walk across room heel to toe Smooth, coordinated movements. Walk on tiptoes, then walk on heels Able to walk on tiptoes and heels without difficulty. Romberg sign negative Shallow knee bend Unable to perform due to knee pain ROM of spine Normal range of motion
15 D1. Lab tests that need to be ordered for KB before she heads to surgery would be a chest x-ray to make sure patient does not have any cardiac issues or any fluid build up on the lungs. A EKG needs to be ordered before patient goes to surgery to observe for any cardiac problems before patient goes under anesthesia. I would also request to obtain a copy of the MRI of the knee to put in patient’s records and review. Blood tests that need to be obtained are •CBC will help to identify if WBC are elevated which could identify an infection. Hemoglobin and hematocrit which would determine if a patient is anemic and requiring a blood transfusion before or during surgery. •Type and Cross in case patient would require blood during or before surgery. •PT/PTT/INR to determine a patient’s clotting before surgery, to determine if the patient has a bleeding problem that needs to be addressed before surgery. •CMP this test identifies if the kidneys are functioning well. If your electrolytes are normal or need to be addressed before surgery and anesthesia. •LFT this addresses your liver function and will identify if you may have a problem clearing the anesthesia from your system. •TSH to determine the affect of the patient’s Synthroid if the medication needs to be adjusted. E. A comprehensive health assessment goes beyond the physical assessment which assess a patient’s systems from head to toe. A comprehensive assessment assesses a patient’s social determinants and health disparities in addition to the physical exam. By doing a comprehensive assessment versus only performing a physical assessment the healthcare provider is able to help identify what may affect a patient’s health.
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- Spring '17