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.
Nurses You Move Me 