Passage / Scenario

History and Physical

Diabetes mellitus type 2 for 15 years
Hypertension for 25 years
Hyperlipidemia for 20 years
History of smoking 40 packs per year
Cerebrovascular accident (CVA) 5 days ago
Nurses' Notes
Day 1, Medical-Surgical Unit (5 days post-CVA):
Client transferred from ICU via gurney, hand-off report received. Client asleep, respirations eupneic, heart rate regular. Abdomen soft, nondistended, active bowel sounds x4 quadrants. No edema noted, compression stockings present. Indwelling urinary catheter draining clear yellow urine. 14 French NG tube noted in right nares, clamped.
Day 2, Medical-Surgical Unit (6 days post-CVA):
Assessment completed. Client awakens for short periods of time, unable to speak, occasional moans noted. Client incontinent of stool, cleaned skin and barrier ointment applied. Skin intact without any areas of erythema. Client unable to reposition self. Occasional movement of left arm and leg noted, right side without movement. Physical therapists in to see client for morning exercises. NG tube noted in right nares, clamped.
Provider Prescriptions
Day 1, Medical-Surgical Unit (5 days post-CVA):
Begin clopidogrel 75 mg via NG tube daily

Diagnostic Results

Day 1, Medical-Surgical Unit (5 days post-CVA):
WBC count 6,900/mm3 (5,000 to 10,000/mm3)
Hgb 16 g/dL (12 g/dL to 16 g/dL)
Hct 41% (37% to 47%)
Platelet count 310,000/mm3 (150,000 to 400,000/mm3)
Day 2, Medical-Surgical Unit (6 days post-CVA):
WBC count 7,200/mm3 (5,000 to 10,000/mm3)
Hgb 16.5 g/dL (12 g/dL to 16 g/dL)
Hct 42% (37% to 47%)
Day 1, Medical-Surgical Unit (5 days post-CVA):
WBC count 6,900/mm3 (5,000 to 10,000/mm3)
Hgb 16 g/dL (12 g/dL to 16 g/dL)
Hct 41% (37% to 47%)
Platelet count 310,000/mm3 (150,000 to 400,000/mm3)
Day 2, Medical-Surgical Unit (6 days post-CVA):
WBC count 7,200/mm3 (5,000 to 10,000/mm3)
Hgb 16.5 g/dL (12 g/dL to 16 g/dL)
Hct 42% (37% to 47%)