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Nursing Case Studies

Decent Essays

CC
Mr. Brann is a 42-year-old male here today for followup from his left cerebellar stroke and left vertebral artery dissection, status post hospitalization in May of 2015
HPI
Since I had seen the patient at his last visit on June 5th, he has gotten married to his fiance Sandra Allen and they are actually planning on moving to Florida. They will be moving on July 31st together to St. Augustine, Florida. He already has an appointment scheduled with a family physician on August 11th and plans on seeing a neurologist as well. He has been to see Karen Lauze, MD in follow up since his stroke. I do not have a note from that visit. She reportedly told Mr. Brann that he could stop his aspirin but to continue with his other current medications. …show more content…

He is alert and oriented. Very pleasant.

Neck
Supple. No bruits or JVD. No masses or tenderness.

Heart
Regular rate and rhythm. Normal S1, S2. No murmurs, rubs, or gallops.

Lungs
Clear bilaterally with good breath sounds. No wheeze or rhonchi.

Abdomen
Soft and nontender. No masses or discomfort.

Neurologic
His gait is normal. No obvious discrepancies in the eye and mouth movement of his face during our discussions here in the office.

A/P
Whitney Brann is a 42-year-old male here today for …show more content…

We talked about the importance of maintaining his medication regimen. I have encouraged him in the future, if he is having any problems with the pharmacy to contact us immediately to assist him and I did write him a refill of his atorvastatin to restart that at 20 mg daily #30 with no refills. At that point, he will be with his new physician and can have his blood work done with them for the lipids and the liver function testing. He does have a lab slip given to me at his last visit for a recheck so that if he does have his visit with her changed in early August, he could do labs for me and I can notify him about any changes that need to be made. He is to continue with his Coumadin. We had a very long discussion about the fact that he has not had his INR drawn as recommended. I reviewed the risks associated with INR value that is too low, as well as an INR value that is too high. He assured me that he would do the INR either today or tomorrow and he knows to contact me within 24 hours of doing the testing if he has not already heard about the result in the meantime. I emphasized the absolute importance of this. He will continue to monitor for any worsening neurologic deficits. Any concerns, he will call 911 and be seen immediately at the

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