I have to complete a concept map on this patient I had this past weekend. The good thing was that she was basically in great shape other than what she was admitted for and it makes it a little hard to come up with my diagnoses. Here is the pt info:
78 y/o female who is totally independent (own bath, ambulation with no assistance, no fall risk, 15 GCS)
Her admitting diagnosis was GI Bleed and anemia.
She had noticed about 4 days prior to admission that she was getting very tired, weak, and fatigued. Also noted that her stools were black and tarry (GI Bleed). She had an endoscopy procedure which showed she had hiatal hernia with lesions which were causing the tarry stool. She was treated with Protonix (antiulcer agent) and now will be on lifelong Protonix at home. They already knew about the hiatal hernia so that is not a new finding. She said she developed the hiatal hernia and since it went undiagnosed for so many years she now has some HTN and Stage II Kidney Disease (both of which are well controlled). No smoking, no drinking. Lives with very nice spouse and talks of great relationships. Retired and comfortable. Nothing unusual on her assessments.
The only labs she had drawn were: PT: 13.1, INR 1.2
(she is on coumadin therapy for a fib and HTN), HGB 7.9, HCT 24.0 on 10-28-11
and HGB 10.7 and HCT 32.6 on 10-29-11
Her VS during my shift were: BP 106/64 and 99/62, Temp 36.8, 02 sat 95% on room air, RR 20, 62 HR. She had absolutely no pain during and experienced no fatigue, etc during the shift. She had good understanding of everything that was going on and understood all her meds so she is very humble and compliant.
She was discharged at the end of my clinical day because they were comfortable with her HGB and HCT levels.
I just don't see too much going on with her so I'm a little if'y about what to do my concept map on.
I need at least 2 diagnoses. The diagnosis I came up with prior to meeting the patient was Risk for Injury r/t abnormal blood panel.