S:

51 y/o F, with a PMHx of HTN, CKD, asthma and substance abuse with last cocaine use six days ago, with surgery consult for permcath placement and AVF creation secondary to renal failure. Today is the patient’s fourth day of admission. Patient reports no overnight events. She states that the hospital is not following a renal diet for her, and she has been unable to eat because of it. Patient states she had hemodialysis earlier, with no complications. She currently reports a headache but denies any fever, chills, weakness, fatigue, nausea, vomiting, abdominal pain, chest pain, SOB, change in urinary frequency, dysuria or any other symptoms.

PMHx: HTN, CKF, substance abuse

PSHx: none

Allergies: NKDA

Medications: Losartan 100mg PO once daily, Amlodipine 10mg PO once daily, Albuterol 2 puffs every 4-6 hours PRN for wheezing

FHx: non-contributory

Social Hx: current smoker, admits to cocaine use, denies alcohol use

O:

VS: Temp 97.6 F, HR 110 bpm, RR 17 breaths/minute, O2 saturation 98% on room air, BP 150/90, Ht 5’5”, Wt 147 lbs, BMI 24.47 kg/m²

PE:

General: Patient resting in bed on cellphone. Alert and oriented x3. No acute distress

Skin: warm and dry. Right femoral shiley in place

HEENT: No gross abnormalities.

CV: Regular rate and rhythm. No murmurs or rubs.

Respiratory: CTA bilaterally

Abd: Flat, symmetrical, soft, nontender, nondistended, normal bowel sounds.

Ext: FROM, no lower extremity edema

Psych: Mild agitation

Labs:

2.62 | 7.3 | 82

           22.6

137 | 96 | 59    98

4.6  | 28 | 9.55

Calcium: 8.3

PTH: 246

Anion gap: 13

eGFR, non-African American: 4.3

eGFR, African American: 5.2

Magnesium: 2.9

Phosphorus: 7.9

CT abdomen/pelvis 2/9/21: Minimal scarring at lung bases, left greater than left. Mild cardiomegaly with trace pericardial effusion. Liver, spleen, pancreas, gallbladder and adrenals unremarkable. Severe cortical atrophy. No right sided nephrolithiasis. Dilatation right renal pelvis likely due to chronic UPJ obstruction. No evidence of left sided hydronephrosis or nephrolithiasis.

A:

51 y/o F, with a PMHx of HTN, CKD and substance abuse with last cocaine use six days ago, who was admitted to the hospital with surgery consult for permcath placement and AVF creation secondary to renal failure.

P:

Continue inpatient medications: Zofran 8mg q8h PRN for nausea, Amlodipine 10mg PO for blood pressure, heparin injection 1,000 units three times weekly PRN

Repeat BMP today

Continue monitoring vital signs

Renal diet

Continue on dialysis schedule

Venous mapping of bilateral UE

Schedule for permcath placement and AVF creation