Patient Information for Paper Diagnosis Topic for Paper: (ESRD) END STAGE RENAL DISEASE

Patient Information for Paper
Diagnosis Topic for Paper: (ESRD) END STAGE RENAL DISEASE
Admitting diagnosis hospital: Pericardial effusion (fluid overload) (chest pain-complaint)
History of diagnosis:
• End Stage Renal Disease
• Chronic Kidney Disease Stage 3
• Diabetes Mellitus
• Falls
• High Cholesterol
• Pneumothorax
• Abnormal vaginal bleeding
• Hypertension
• Hyperlipidemia
• Brease Cancer
• Hypothyroidism
• Hypokalemia
• Iron Deficiency Anemia
• Morbid Obesity
Labatory Values:
CBC
• WBW 13.1 elevated above normal level
• RBC 3.75 below normal level
• HEMOGLOBIN 10.5 below normal level
• HEMATOCIT 32.1 below normal level
• NEUTROPHILS 85.4 elevated above normal level
• LYMPHOCYTES 6.1
RENAL FUNCTOIN (KIDENYS)
• PHOSPHORUS 5.6 elevated above normal level
• GLUCOSE (blood sugars) 244/228 elevated above normal level (70-110)
• BUN 42 elevated above normal level
• CREATITINE 8.00 elevated above normal level
• SODIUM 132 below normal level
• EGFR
SKIN: wound noted to Left lower extremity (patient states area started off as callus, then it opened, and
became a wound and spread)
Blood Sugars for this shift:
• 06:29 am BS 228
• 10:56 am BS 216
• 16:17 pm BS 119
Other patient information:
• Patient on Oxygen at 2 liters via N/C
• 20 Guage IV to right hand
• The chest tube that was removed 4/8/2022 in the am that was placed for the pericardial
effusion to Left Flank area of body and patient was on low continuous suction.
• NO KNOWN DRUG ALLERIGES
• PATIENT ON REGULAR RENAL DIET WITH THIN LIQUIDS
• Patient has dialysis on M/W/F for Kidneys. Last dialysis 6 liters of fluid was removed from
patient.
• Alert and oriented X4 (person, place, time, and situation)
• Uses Novolog insulin to help control Diabetes Mellitus
• 08:00 am set of vitals were BP (Blood Pressure) 122/71 P 63 R 18 T 97.9 SPO2 99% on 2 liters of
oxygen via N/C
• Can ambulate with oxygen and assist X1
• Continent of bowel and bladder
• R upper chest port for Dialysis
• Vitals before dialysis BP 121/73 P 93 R 18 T97.9 SPO2 94% @11:49 am
• Height 162.6cm (5’4)
• Weight 183 lbs = 83.41 kg
• High blood pressure and Diabetes Mellitus are risk factors for kidney disease
• Fall Risk
• Possible discharge home today
Medication that patients is currently taking:
• Norvasc 10 mg tablet for hypertension
• Tylenol 650 mg tablet for pain prn q 4 hours
• Sevelamer (Dialysis Patients) for binding purposes
• Rosuvastatin for Hyperlipidemia
• Metoprolol for hypertension
• Levothyroxine for hypothyroidism
• Glucagon PRN for Diabetes Melius
• Doxycycline 100mg tablet BID for cellulitis (bacterial infection)
• Dextrose 25 mg IV push for hypoglycemia
• Dextrose 50% 12.5-gram IV push for hypoglycemia