Gordon Feldman at 01 - 14 - 2023 09 - 19 PM
Gordon Feldman at 01 - 14 - 2023 09 - 19 PM
Gordon Feldman at 01 - 14 - 2023 09 - 19 PM
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Patient Data
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Basic Information
Date:
01/14/2023 21:20:00
Author:
Brandi Kam
Location:
General Hospital
Assessment:
The man was well until four days ago when he presented with a one day history of abdominal pain, diarrhea, vomiting, and nausea.
The patient has had an history of hemodialysis, and has been on peritoneal dialysis for now two years. The abdominal pain is not
relieved even with strong anti-pain medications like morphine. He had to miss his last dialysis due to his chronic abdominal pain. CT
scans of the abdomen shows no positive findings. She was put on empiric antibiotic cover for as one of the differentials was
peritonitis. The patient reported to be feeling better on the fifth day of admission.
Admitting dx:
PMH:
HIV disease
Hypertension
End stage renal disease on dialysis
Chronic renal failure
Secondly hyperparathyroidism
Hematuria
Cystitis
Hyperkalemia
Anemia
Diverticulitis of Colon
Postoperative serum
Ht:
188 cm
Wt:
99.7 kg
BMI:
28
IBW:
190
Diet Rx:
Diagnosis Ritonavir food interaction as evidenced by chronic diarrhea and chronic abdominal pain impairing nutrient absorption
causing anemia evidenced by the low hemoglobin levels.
The elevated creatinine and BuN levels are related to the kidney disease.
Relevant meds:
Relevant labs:
CBC
HGB 11.4 L
HCT 35.4 L
WBC 9.4
PLT 188
RBC 4.19 L
MCV 84.5
MCH 27.3
MCHC 32.3 L
RDW 17.3 H
MVP 8.4
CMP
NA 144
K 5.3 H
CL 109 H
CO2 23
ANION GAP 12
BUN 87 H
CRT 13.8 H
EST GFR (AFRICAN) 5 L
EST GFR (NON-AFRICAN) 4 L
BUN/CRT 6.3 L
CALC OSM 313 H
CA 9.5
TOT BILI 0.3
AST 27
ALT 18
C-REACTIVE PROTEIN <0.5
TOTAL PROTEIN 7.4
ALBUMIN 4.0
GLOBULIN 3.4
HCO3 23
GLUCOSE 84
Kcal:
2492.5-2991 kcals
Protein:
Diagnosis (nutrition):
Altered nutrition-related lab values related to acute kidney injury AB increased BUN and creatinine.
Nutrition goal(s):
Currently patient on full liquid diet. Advance renal diet with modified protein restriction of 103.2 - 129 grams per day and 2492.5-
2991kcal calorie diet.
Intervention
Recommendation:
Collaboration of care:
Appropriate amounts of macro- and micro-nutrients with particular emphasis on vitamin B12, iron, and folate.
Monitor/evaluate:
Follow up to monitor the progression of the symptoms. Check weights and labs.