Week Eight Journal Entry: Renal Disorder

Mrs. Kid Knee was a fifty-nine-year-old African-American seen in the clinic for complaints of shortness of breath. She skipped her dialysis the day prior. She had a medical history of atrial fibrillation, hypertension, congestive heart failure, peripheral vascular disease, chronic obstructive pulmonary disease, diabetes mellitus and end-stage renal disease with hemodialysis. She was a former one pack per day smoker for forty years. She quit smoking one year ago. She denied the intake of alcohol. She had a left arm fistula placed for dialysis six months ago. Her family history included a mother and sister with diabetes and heart disease. Her father, mother and sister had hypertension. Her immunizations …show more content…
Mrs. Kid Knee vitals were as follows: blood pressure 139/60 mmHg, temperature 97.7 °F, heart rate 56, respirations 20. Her weight was up five pounds from last visit that was one week ago. She was a well- dressed woman. Her skin was warm, dry and intact. The mucous membranes were moist, and hearing was intact. Rales were auscultated in her right lower lung field. Her cardiovascular system was negative for chest pain. There was not any jugular vein distension, audible gallop, or heart murmur noted. She had bilateral +1 pedal edema, and peripheral pulses were found to be +2 at the radial and pedal location. Abdomen was soft with normal bowel sounds. An electrocardiogram showed a sinus rhythm with a first-degree heart block. Pertinent labs from the previous visit were as follows: WBC was 10.3, Hgb was 9.7, potassium 5.2, creatinine 3.2, BUN 24, GFR 27 and thyroid function studies were normal. Chest x-ray did not show significant change from her previous exam. However, there was significant cardiomegaly present. The diagnosis was volume overload with end-stage renal disease. There were no changes made to her medications at this time. Plan of care was discussed with her, and contact was made with her nephrologist. She was sent to the center for