Patient’s Personal And Medical History  Coursework Example

NURSING COURSE WORK
Student’ name
Institutional affiliation

Patient’s personal and medical history
Name: Jane
Reporter: Jane
ID: 31 years
Jane is a 31 years old woman .she was presented to A&E department after a GP referral. She feels pain in her left calf. The pain started a week ago .she was diagnosed with acute appendicitis and she was admitted to the hospital. She complains of a pain in her thigh which has been there for a week.
Drug therapy and treatments
The entire leg of the patient is examined .the following information was obtained after examination (Wells & Anderson 2013).
Her heart rate is 70 beats
.Left calf 38.0cm/minute
Right calf 34.0 cm,
Left thigh 56.0 cm
Right thigh 52.0 cm
Blood pressure 120/80
Jane is suspected to be having a DVT.A two-level DVT will be used to establish the DVT clinical probability (Wells & Anderson 2013).
DVT Wells score for Jane is 3.
Bedridden for over 3 days=1
Whole leg swollen=1
Immediate proximal leg ultrasound is offered to the patient. The treatment can be conducted by 3 hours after requesting. A D-dimer test will be offered if the results are negative. The test is necessary for determining the DVT (Di Nisio et al 2015).
The ultrasound scan revealed that Jane has occlusive clot.it was found at the common femoral vein.
LMWH is offered immediately after diagnosis for a period of 5 days. Jane will be offered with catheter-directed thrombolytic therapy. Patient preferences and monitoring facilities should be considered before offering the patient with catheter-directed thrombolytic therapy.

Jane should visit an outpatient clinic in 3 months (Di Nisio et al 2015).
Follow-up care
Jane will be provided with below-knee after one week. The below-knee stocking should be replaced twice a year. Jane should visit the health facility after three months for a check-up (Di Nisio et al 2015).
References
Wells, P., & Anderson, D. (2013). The diagnosis and treatment of venous thromboembolism. ASH Education Program Book, 2013(1), 457-463.
Di Nisio, M., Lee, A. Y. Y., Carrier, M., Liebman, H. A., & Khorana, A. A. (2015). Diagnosis and treatment of incidental venous thromboembolism in cancer patients: guidance from the SSC of the ISTH. Journal of Thrombosis and Haemostasis, 13(5), 880-883.