ESRD - Admission note for ESRD on HD

CC: SOB x ... hours/days
HPI:
- Onset
- Setting in which occurred - what Pt was doing at that time
- Manifestations: ChLoRIDE PP (not necessarily in this order)
  - Character
  - Location
  - Radiation
  - Intensity or severity
  - Duration and time course
  - Events preceding onset of the complaints
  - Provoking/Exacerbating factors/Aggravating factors
  - Palliating/Alleviating factors
  - Similar problem before
- Pertinent +ve and -ves: (may record some in ROS)
  - N/V/D.
  - Dypnea, othopnea, PND, swelling (peripheral, periorbital, anasarca), ascites.
  - CP, palpitations, diaphoresis, syncope
  - HA, dizziness, light-headed, blurred vision, sz, weakness, numbness, paresthesiae.
  - Fever, chills, rashes, cough, +/- sputum, wheezing, sorethroat, rhinorrhea, arthralgia.
  - Claudication, calf pain
  - Exposure to sick contacts, recent travel
  - GIB
  - Does Pt make urine?
    - dysuria, hematuria, flank pain, etc.
  - HD days, last HD, access site, problems with graft, shunt, fistula, permacath.
  - Previous ABx therapy.
  - Compliance with meds, diet, and fluids.
- PPD, Flu shot this year, pneumonia vaccination.
- ER w/up, Tx given
ALLERGIES:
MEDS:
PMH:
- ESRD on HD, since when?
- Dialysis center - where?
- Nephrologist
- Access - AVF, AV graft, HD catheter
- MI, CAD, HTN, CHF, PCI, 2D-echo (LVEF), DCM, PPM, AICD, arrhythmia
- DM
- COPD, Asthma, Pneumonia, Prior intubations
- Stroke
- CA
- PUD
- PVD
- DVT
- EGD, Colonoscopy
- Hepatitis-B, C
PSH:
OB&GYN (if pertinent)
FMH:
SH:
- Tobacco use pk/yrs; rec. drugs type/amt/freq/last use; ETOH type/amt/freq/last use; env. hazards, use of safety devices, home situation and significant others; social support systems); ADLs and IADLs, diet, caffeine, sleep pattern, level of education, emp. hx, sexual activity, risk behavior profile, exercise and leisure activities, travel, impact of illness on the patient's life-as a person, worker, spouse, and parent.
- ADL/IADL

ROS: unremarkable apart from the above symptoms