Patient Mrs L.S.
History of present A 76 yrs old Female Patient present to WEC reported feeling Weakness in her lower/left leg/foot &has some residual pain and swelling in lower/left leg feeling weak and more so on standing/walking. And SOB.Pt has had a recent vascular surgery on her lower /leg /foot 2 months ago and has some and dizzy more so upon standing/walking.Pt reported that she has deteriorated after operation .Pt afebrile,AF ryth on cardiac monitor all other Obs within normal ranges.
History of past illness Hypertension ,Palpitation Problem ,VASCULAR Surgery lower /left leg 2 months ago.
Attachmements Placed on a cardiac monitor,indication AF rhythm,
Medications Sotalol 80 mg BD for her rhythm disturbances cardiac arrhythmias of her heart.Metoprolol 25 mg nocte abeta blocker to assist her heart circulation ( blood flow through her arteries and veins) and her hypertension.Rosuvastatin 10 mg nocte to lower risk of coronary artery disease and lower cholesterol levels in blood.Frusemide 40 mg BD is loop diuretics used to help relieve fluid retention oedema and also to lower BP.Tramadol 50 mg BD to manage her pain.
Allergies no allergy
Social Life ; Drank Beer but never smoked
Family Life : Her mother died of M.I 10 YEARS AGO.,She has a husband and 3 children her son has cardiac problems.
Extremities Oedema swelling in Lower /left leg/foot
Plan : Vital signs 4QH BP 154/80, HR 89 ,Temp 36.5,RSP 20,cardiac monitor indicating AF rhythm, Pulse ranging between 64 and 78,BP 130/80,RSP 18 to 20, 24 Hr urine collection ,Lung sound clear to auscultation,O2 Sats 99 percent, Temp 36.5,Pain controlled with Tramadol 40mg.Tramadol given with good effect.
Assistance x 1 assistance with mobilisation and she has weakness in left leg,physio will review her this afternoon as she is found it almost impossible to get out from the chair without using her arms and swinging up.
swelling in extremities which is managed by Sotalol 80 mg BD,metoprolol 25 mg nocte, Frusemide 40 mg BD
Tramadol 50 mg BD tto manage her condition.MRI scan negative,blood collected and send to SPN awaiting
A 76 yrs old female presented to ward this morning with palpations ,left leg / foot weakness ,pain and for blood results,3/24 urine collection,cardiac monitor indicating AF.Patient observations to be done Q4H. Pt mobilising with x 1 assistance due to her Left leg /foot muscle weakness and Pt is a high fall risk and falls risk chart initiated and other assessments eg pain chart for Q4H.Pt to be reviewed by Physio at 2 pm
.Dr David ,C came this morning and ordered blood to be collected to investigate whats causinPatient Summary
her muscle weakness.Dr will be coming back this afternoon to discuss her .discharge plan and to check her blood results.Pt is tolerating food and fluid well.Obs Q4H all within normal ranges,Pt bowels opened this Pm.Pt resides with her daughter. k and falls risk chart initiated and other assessments eg pain chart for Q4H.Pt to be reviewed by P
hysio at 2 pm .Dr David ,C came this morning and ordered blood to be collected to investigate whats causin g Patient Summary