Clinical Scenario: REASON FOR CONSULTATION: INR of 4.8 HISTORY OF… Clinical Scenario:REASON FOR CONSULTATION: INR of 4.8  HISTORY OF PRESENT ILLNESS:  Mrs. X is a 79-year-old Caucasian female who accidently slipped and fell today resulting in a left femoral neck fracture who was admitted to the orthopedic service and will have surgery tomorrow. She denies any prodrome prior to the fall. She specifically denies any chest pain, palpitations, shortness of breath, dizziness, syncope, or near syncope prior to the fall. Of note she hit her head during the fall. The ED completed a CT of the head and no acute bleeding was noted. A hospitalist consult was requested because her INR upon evaluation in the ED was 4.8. She has a history of atrial fibrillation and a mechanical aortic valve. The mechanical valve is a St. Jude valve which was placed 12 years ago at an outside facility. She normally takes 3mg of Coumadin daily at home, does not recall her last INR and states she has been compliant with her medications and diet. Denies any black or red stools, hematemesis, or hematuria.Review of Systems:Constitutional: Negative for diaphoresis, chills, fever, and fatigue. HENT: Negative for hearing loss, ear pain, nose bleeds, tinnitus.Eyes:Negative for blurred vision, double vision, photophobia, discharge or redness. Respiratory: Negative for hemoptysis, wheezing, cough. Has intermittent shortness of breath at home.   Cardiovascular: Negative for chest pain, palpitations, orthopnea, leg swelling or PND. Gastrointestinal: Negative for heartburn, nausea, vomiting, abdominal pain, diarrhea, constipation, blood in stool or melena. Genitourinary: Negative for dysuria, urgency, frequency, hematuria and flank pain. Musculoskeletal: Negative for myalgias, back pain and falls. Positive for left hip pain.Skin:  Negative for itching and rash. Neurological: Negative for dizziness, tingling, tremors, sensory changes, speech changes. Endocrine/hematologic/allergies:  Negative for environmental allergies or polydipsia.Psychiatric:  Negative for depression, hallucinations and memory loss.Past Medical History:Diabetes mellitus Type 2, with peripheral neuropathy- diet controlledCoronary Artery Disease- S/P CABG x2Atrial fibrillation- S/P ablation 14 years agoSt. Jude Mechanical valve replacement 12 years agoDyslipidemiaHypertensionCOPD on 2L of oxygen via NC at homeLeft ventricular hypertrophy- Last Echo 10 months ago with an EF of 60%Past Surgical History:CABG x2 in 12 years agoCataract extraction 10 years agoRight lower lobe lobectomy for carcinoid tumor 15 years agoTotal abdominal hysterectomy 30 years agoIntracranial aneurysm repair in 37 years agoLeft total knee replacement secondary to osteoarthritis 6 years agoFAMILY HISTORY: She is unaware of her parents or siblings medical historySOCIAL HISTORY:  She denies any smoking or alcohol use.  She denies any drug use. Lives in an assisted living facility.MEDICATIONS:Coumadin 3mg PO dailyCrestor 10mg PO daily at bedtimeLosartan 100mg PO dailyMetoprolol Succinate 50mg PO dailyNifedipine 60mg PO dailyZoloft 50mg PO dailyTricor 145mg PO dailyALLERGIES:  NonePHYSICAL EXAMINATION:Vital signs:  36.4, 100, 26, 126/71, 96% on 2L NC. Constitutional:  Alert and oriented to person and place.  Nontoxic, no acute distress.Head:  Normocephalic and atraumatic. Scalp laceration with sutures and dried blood on occiput. Nose:  Midline, right and left maxillary and frontal sinuses are nontender bilaterally.Oropharynx:  Clear and moist. No uvula swelling or exudate noted. Eyes:  Conjunctivae, EOM and lids are normal.  PERL. Right and left eyes are without drainage or nystagmus.  No scleral icterus.Neck:  Normal range of motion and phonation.  Neck is supple.  No JVD.  No tracheal deviation present.  No thyromegaly or thyroid nodules.  No cervical lymphadenopathy noted bilaterally.Cardiovascular:  regular rate, S1 and S2 without murmur or gallop. A click is present.  Brachial, radial, dorsalis pedis, and posterior tibial are 2+/4+ bilaterally.Chest: Respirations are regular and even. Lungs are clear in the anterior and posterior fields. .Abdomen:  Soft.  Bowel sounds are active, nontender, no masses noted.  No hepatosplenomegaly noted.  No peritoneal signs. Musculoskeletal:  Full range of motion of the bilateral shoulders, wrists, elbows. Left hip ROM is limited.Neurologic: Cranial nerves II-XII are intact.Skin:  Warm and dry. Psychiatric:  Mood and affect are normal.  Calm and cooperative.  Behavior, judgment is intact.LABORATORIES AND DIAGNOSTICS:WBC 11.5, Hgb 12.5, Hct 36, Platelets 175,000Creatinine 1.1, BUN 22INR 4.8UA- negativeAll other labs are unremarkableCT of Head (non-contrast)- no evidence of acute intracranial hemorrhage.X-ray of left hip-left femoral neck fractures:Develop a list of differential diagnoses specific to the elevated INR. What are the four most important differential diagnoses to consider?Based on the available clinical data, what is your diagnosis as it pertains to the reason for consultation?What additional diagnostic tests should be ordered to further evaluate the reason for consultation?Write a treatment plan for the following two diagnoses/scenarios: Supratherapeutic INR (Preoperative Management), Atrial Fibrillation & Aortic Mechanical Valve (Post-operative anticoagulant management-only focus on the anticoagulation management). All written orders must have complete instructions. For instance, a medication order must have the name, dose, frequency, and route. Lab orders must include the lab name and frequency. If an order should be done now, stat, urgent or routine that also should be indicated.What is the most appropriate level of care for this patient?What physician specialty or other interprofessional consults should be ordered?What anticipatory guidance/patient education should you provide to the patient?Health Science Science Nursing NURS 5463

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