Norma Blok Case
This is a 93-year-old female who presents to follow up on multiple medical conditions. She is here with her son. Chief Concern: Ear feels blocked, skin tear, check on heart and lungs. HPI: Mrs. Norma Blok is a 93-year-old woman who recently had a TAVR aortic valve repair. She has done quite well with this. She recently saw the nurse practitioner for the TAVR team, who called me concerned about a cough. Norma had been coughing for a little over a week. The cough was feeling congested with some white sputum output. It was getting worse rather than better. Cough syrup had not helped and so the nurse practitioner and myself decided to treat her. She was subsequently put on Augmentin, has just a few days left. She is feeling much, much better. …show more content…
Her son updated me on medication changes. Her diuretic has been stopped. She does continue to have some leg edema, although it is much better than it used to be. She is wearing compression stockings and trying to elevate it as much as possible. She does avoid salt. The edema is mostly around her ankles and her lower legs and it does not really bother her. She has a feeling that her left ear is blocked. It does not hurt and she has no pain but does notice her hearing is decreased. Assessment and Plan: Alzheimer’s disease: She has mild Alzheimer’s disease. She is currently in assisted living and her son sets up her medications in a pill reminder. She keeps this next to her toothbrush so she has only missed 1 dose of medications in a very long time. She seems stable and in a good situation for now. Acute bronchitis due to other specified organisms: She probably had bacterial bronchitis and as noted above, has been on Augmentin. She should complete this course but her lung exam is much improved. Persistent atrial fibrillation: She was in sinus rhythm today but has been known to be in atrial fibrillation most of the time. She is on digoxin for rate control and her amiodarone has been discontinued. She remains Eliquis for anticoagulation and stroke prevention. She has no bleeding issues from
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