Which of the following selections from the above documentation best reflects the history?

a. Eyes are clear without signs of jaundice . . . heart and lungs are clear without abnormal sounds . . . she does not appear uncomfortable during the abdominal examination . . . Edna displays a full range of motion when extending her left knee and ankle with no referring pain along upper leg or in hip
b. Patient tripped on an ottoman in her house . . . no reported dizziness or shortness of breath after the fall . . . however, large bruise formed on the anterior surface of her lower left leg. This morning, Edna noticed that her lower left leg was swollen and the bruise was darker and warmer than the surrounding skin . . . patient is currently undergoing anti-platelet therapy . . . patient suffered a stroke three and a half years ago
c. Due to Edna's anti-platelet therapy, a PT/INR test is important to identify clotting concerns. Edna has been educated about the signs and symptoms of a clot
d. No history has been documented for this service


b) Patient tripped on an ottoman in her house . . . no reported dizziness or shortness of breath after the fall . . . however, large bruise formed on the anterior surface of her lower left leg. This morning, Edna noticed that her lower left leg was swollen and the bruise was darker and warmer than the surrounding skin . . . patient is currently undergoing anti-platelet therapy . . . patient suffered a stroke three and a half years ago

Health Professions

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