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Chronic Kidney Disease
Diagnostics
EKG
Rhythm: Regular
Rate:90
PRI:0.12
QTI:0.40
Final interpretation: Normal sinus rhythm
Echocardiogram-Put on due to HTN on admission
Conclusion-Decompesated HF
XR Chest-Conclusion-pulmonary edema due to HF
US retroperioneal-Conclusion renal disease slight blood flow to both kidneys
LABS
Admit Diagnosis HTN,SOB
Home Meds
PMH: DM2,HTN,CKD
PSH: Vasectomy
Allergies:Tramadol (Tongue swells)
Code status: DNR
Fall risk: No
Isolation: No
Core measure: HF & VTE
Amlopine 10mg/tab/Oral/Daily
Hydralizine 50mg/tab/q8hr
Insulin Glargine 15 units, SQ, inj, QHS
Insulin Lispro 1-6 units, SQ, inj, TID w/meals
Insulin Lispro 5 units, SQm inj, TID w/meals
Vital Signs
0730
T:36.7, HR:93, RR:18, B/P:149/83, MAP:105, SP02:98% RA
1100
T:36.9, HR:79, RR:19, B/P:145/82, MAP:103, SP02:99%
RA
HPI
Current Meds
51 year old male who presented to ED w/SOB that began at 2am 3-2-24.Pt reports SOB acompanied w/cough which also started on 3-2-24 morning, Pt reports cough was productive of bloody pheglm, blood was small amounts ocurred approxamitley 10X, pt is noted to be hypertensive presenting with likley acute decompasated heart failure causing volume overload and pulmonary edema. while in ED pt with SOB saturating at 89% on 2l oxygen via NS, w/RR 34, placed on BIPAP 12:8 30% FIO2 and saturating on 100%, w/RR 19, elevated B/P 251/140 on admission, was given nitroglycerin 0.4mg, enalpril IV, lasix IV, NTG drip improvement in B/P 179/100, 3-3-24 patient states he is feeling better no longer SOB, 3-2-24 chest xray was done pulmonary edema was noted, 3-3-24 US retroperiotoneal slight blood flow in both kideneys was noted.
Amlopine 10mg/tab/Oral/Daily
Hydralizine 50mg/tab/q8hr
Insulin Glargine 15 units, SQ, inj, QHS
Insulin Lispro 1-6 units, SQ, inj, TID w/meals
Insulin Lispro 5 units, SQm inj, TID w/meals
Calcitrol 0.25mcg/tab/oral/daily
Calcium Carbonate 1000mg/tab/oral/BID
Ergocalciferol 5000/cap/oral/weekly
Furosemide 80mg/IVPUSH/TID
Heparin 5000units/subQ/Q8hr
Magnesium oxide 800mg/tab/daily
Metroprolol 50mg/tab/oral/daily
Potassium chloride 10meq/tab/oral/daily
Sodium carbonate 1300mg/tab/oral/bid