538 Case Scenario.Worsening Shortness Of Breath/AKI/ S/P Fluid Overload.


Account number Q005634372.

MR # Q00069593424.

Admitted date 09/23/2020.

Status Admitted Inpatient.

Location General Surgery.

Room: 62114.

Attending doctor Tommy Holbib.

Patient name: John Knot Drum.

Resuscitation Status: Full Code.

Weight 152lbs.

Height 5feet 6inches .


Transportation method: Bed.OOB x3.

Sit up during meals.

02 at 2liter NC with Saturation 92%.

Primary diagnosis: Worsening Shortness of breath, AKI, s/p fluid overload.

Secondary diagnosis: Hypertension, DM, BPH, high cholesterol.

Isolation: Standard Precautions.

Does patient have advance Directive: No.

Copy of advance Directive on the chart.

Diet NPO after midnight.

Fistula Surgery. Permacath placement.

On 09/24/2020 Permacath placed left upper subclavan.

Saline lock right forearm 20guage clean/Patent/Intact.

Hemodialysis done. 2liter out.

Diet : Renal diet.( On hemodialysis 90gm protein, 3gm K,3gm Na,and 1gm Phosphorus)

Fluid restrictions of 1liter in 24hours.

On 09/25/2020 discharge home after hemodialysis.

Side rails up,bed in low position and locked. Call light and Personal belongings within reach.

Allen test done.

Vascular ultrasound done.

Vital signs:

Bp 110/67,Hr: 82,Temperature 97.6.

Respiration: 18.

02 Saturation 93% @2liter NC.

Medications Reconciliation done.

Accucheck Qac and Qhs.Sliding scales.


1.During auscultation you have difficulty to determine which sound is S1 and which is S2.How do you decide which is S1?.

2.When you auscultate his lungs you asked him to say “99” and you listen carefully with your stethoscope. You heard muffled sounds that are symmetrical , then diminish towards the peripheral. What would you recognize this as?.

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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