Name Godess, Edwin. 74years, Male.

Attending doctor: Dogood, Heaven.

Status : Inpatient admission.

Account number: Bh00000654.

Unit number: Bh654000009.

Location : Med/Telemetry.

Room number:45400.

Code status: Full Code.

Orientation status: Alert and oriented x4.

Chief Complaint: Light headedness, anemia.

Primary Diagnosis: Anemia.

Secondary diagnosis: HTN,ERSD,Hemodialysis Tuesday/Thursday/Saturday. Done today by doctor Vincent Coconut.

Isolation Precautions: Standard precautions.

Risk for Fall: Yes.

Placed patient on fall precautions protocols.(Yellow gown,yellow fall signs, and armband)

Do patient have advanced Directive?. No .Copy of advanced Directive on the chart.

Interpreter needed?.No.

Next of King : Godess, Knowing 909-999-9999.

Allergy: NKDA.

Diet: Renal diet.(Patient on Hemodialysis =90gprotein,3gm Na,3gm k,1gm phosphorus. Patient not on Hemodialysis =60protein,2gm Na,2gm K,1gm phosphorus)Nephro supplement 1 can lunch and dinner.

Left hand saline lock.

Right subclavian permacath.

Fistula placement next two weeks.

H/H 5.0/18.

3 units of PRBC given.

Hemoglobin 7.9.Hematucrit :24%.K=4.6,NA=136.

Epogen Every Wednesday.

Am labs: CBC, BMP.

Tarry stool.GI consult.

Colonoscopy done findings: Hemorrhoids.

PLANS: Transfer to SNF when medically stable.

Published by edochie99

A Registered Nurse with over twenty years of hospital experience, an author with Masters Degree in Nursing,also Bachelor Degree in Nursing,graduated in 1996 from USC,University of Southern California.MSN in 2009 University of Phoenix.

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