solved

Question
Answered step-by-step
Asked by ChancellorManateeMaster508

Tommy Thompson

78 year old, male

Russian background

 

 

Previous Medical:

1) HTN, 2) Atrial Fibrillation, 3) GERD

 

Family Hx- dad- died of stroke, mum- died of old age.

Medications: metoprolol, dabigatran, omeprazole

Allergies: None

Job: Concert Pianist

 

Presenting complaint:

Tripped over the cat middle of the night. “felt a bit dizzy”” “Got up to go to the bathroom”, “fell forward” “was sore last night, but it is more sore today” “it is hard to move it” “I can’t play piano today” “the floor is hardwood”

No other injuries. 

No loss of consciousness. Full recall of events

Left hand dominant

 

History of complaint:

Onset- after injury- approximately 1am. 

Provocative: better- if I hold it, worse if I move it or push on it

Quality: sharp

Radiation: moves up my arm

Severity: 5/10

Taken Tylenol and Ibuprofen- 15 mins ago “hasn’t helped at all”

 

ON EXAMINATION (Objective)

Temp- 37.2, RR 16, HR- 100, BP 145/82, 02- 98%, alert and oriented x 3, awake. 

Sitting up, holding left wrist.

Appears uncomfortable. 

Look: Syndactyly present- ring and pinky finger. swelling and bruising from mid forearm to mid carpal area. No obvious deformity. No redness. No lacerations.  3cm by 4cm abrasion to palm- over thenar eminence. Bleeding controlled. Slight redness surrounding abrasion. 

Feel: Skin warm and dry. Well perfused. Cap refill < 2seconds. Pain over thenar eminence, no snuff box pain.  Pain on palpation of at distal radius and distal ulna. Nil pain at olecranon, nil pain at medial or lateral epicondyle. Move: Full ROM- active and passive- Elbow. Full pronation and supination with pain- active and passive. Wrist flexion to 20 degrees- active, 30 passive. Wrist extension- 30 degrees active- 40 passive. Special Tests: (see tests below). *please try all against resistance. Some weakness maintaining with "OK sign"    Image transcription text "Peace sign" against Ulnar ner... Show more Image transcription text ulnar Median Radial   Q1. Match medical history and medications     Q2. Define words that are highlighted in yellow     Q3. Name 2 possible NANDA Diagnosis and give a plan for each one.    NANDA Plan 1     2       Q4. Create a SOAP Note with the information provided SCIENCE HEALTH SCIENCE NURSING NRSG 141

******CLICK ORDER NOW BELOW AND OUR WRITERS WILL WRITE AN ANSWER TO THIS ASSIGNMENT OR ANY OTHER ASSIGNMENT, DISCUSSION, ESSAY, HOMEWORK OR QUESTION YOU MAY HAVE. OUR PAPERS ARE PLAGIARISM FREE*******."