Nursing And Rehab Facility For Monthly Renewal Essay

776 Words 4 Pages
Ms. RS is a 95 y/o African-American female seen and evaluated at Hartford Nursing and Rehab Facility for monthly renewal. Resident was sitting in her wheelchair in her room. She was pleasant on approach and she was able to verbalize her needs. Resident did not appear to be in any acute distress at this time. She states that she feels better that last week, but occasionally experiences cramps in her lower legs. She states that has similar episodes in the past that resolve in a few days. She reports no other symptoms.
Reflecting back on my history taking, I think that I did pretty well. I listened attentively, maintained good eye contact, and let the resident express her concerns. The resident’s length of stay was more than a year. So, I mostly reviewed and updated her health history, and medications. The physical exam was remarkable for +3 bilateral lower legs pitting edema. Usually, there are several localized and systemic causes for lower extremity edema (i.e., HTN, HF, RF, DVT, PVD, RA, Lymphedema, Cellulits, Hypoproteinemia, Medications, etc.). However, after a careful history and examination (i.e., acute or chronic; unilateral or bilateral; painful or not painful; skin pigmentation, orthopnea, etc.), I established that her bilateral leg edema was most likely due to heart failure (previous BNP was elevated in the 800 range). Thus, I recommended increasing her Lasix from once a day to twice a day. When I got home, I wondered if I should have increased her potassium dose as…

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