Harold Shoemaker is a 91-year-old male who is on a

Harold Shoemaker is a 91-year-old male who is on a medical floor for treatment of anemia secondary to chronic kidney failure. Currently he is managed at the nursing home. During dialysis today, he was noted to have a hemoglobin of 7.0 and hematocrit of 20% and was admitted for a blood transfusion. Patient Information: Age: 91 years old Marital Status: Widowed Race: Black or African American Height: 72 inches Weight: 200 lbs / 90.7 Kg Occupation: Retired Attorney Advanced Directive: No Code on File Primary Diagnosis: Chronic Renal Failure Allergies: NKA Notes: Physician Note 12:46 Admission History and Physical Subjective Patient is a 91 year old Black male. The history was provided by the nursing home physician and the patient. Currently the patient has been managed at the nursing home for chronic kidney disease. During dialysis today, he was noted to have a hemoglobin of 7.0 and Hematocrit of 20% and was admitted for blood transfusion. Current medications: Lasix 40mg once daily by mouth, Vitamin B 12 SQ injection once per month, Vitamin D 2000 units daily, multivitamin daily 1 tablet, ferrous sulfate 325mg PO once daily. Past family history: kidney failure (father), obesity (father), diabetes (mother) Past medical/surgical history: chronic kidney failure Social history: Retired school teacher, now lives in nursing home, son Sam is involved in care. Review of Systems otherwise as noted above General: No illness, fatigue, fever, or chills Eyes: Does not wear glasses, no eye pain, no eye sensitivity, no eye redness Ear/Nose/Throat: No difficulty hearing, no ear pain, no nose bleeds Lungs: No recent coughing, no wheezing, no difficulty breathing Heart: No high blood pressure, no chest pain, no dizziness, no swelling. Digestive: No increase/decrease in appetite, no recent weight gain, no recent weight loss, no feeding problems, no heartburn, no nausea, no vomiting, no diarrhea or constipation, no pain, no itching, no jaundice. Urinary: No incontinence, no pain on urination, no blood in urine, Blood: No history of anemia, no bruising, no bleeding Muscles/Bones/Joints: no muscle pain, no back pain, Neurological: No headaches, no fainting, no seizures, no weakness, no shakes/tremors. Behavioral: No feelings of sadness, no anxiety/worry, no complaints about being bullied,no forgetfulness Endocrine: No abnormal thirst, no abnormal hunger, no frequent urination Allergy: No intolerances to foods, no anaphylaxis, no allergy testing done Skin: No rashes, no lumps, no acne, no sores/bleeding Objective Exam: General: Alert and cooperative, age appropriate. Oropharynx: Lips, mucosa, tonsils and tongue without edema, bleeding, sores or erythema Eyes: Conjunctivae/corneas clear. Pupils equal round reactive to light and accommodation (PERRLA) Ears: Ears midline and external ear canals both ears. No drainage Neck: No adenopathy, supple, trachea midline and thyroid not enlarged Lungs: Clear to auscultation bilaterally in all lobes, no accessory muscle usage Heart: Regular rate and rhythm, S1, S2 normal. No murmurs, rubs or gallops noted. Abdomen: Abdomen soft and nontender, no hepatosplenomegaly noted Extremities: Extremities normal, no cyanosis or edema Skin: Warm and dry, no rashes Neurological: Alert and oriented to person, place and time. Assessment: In summary, this is an 91 year old Black male that has been admitted for treatment of anemia secondary to chronic kidney failure. Plan: Admit to medical surgical unit Vital signs per floor routine Activity as tolerated Type and cross and transfuse 2 units of PRBCs Medications as ordered in MAR Place IV once now Dialysis 3 times a week on MWF while in the hospital Complete blood count (CBC) and comprehensive metabolic panel (CMP) once in the am after transfusion. Daily weights in the am The risks and benefits of my recommendations, as well as other treatment options were discussed directly with the patient. Questions were answered. Nursing Admission Note 12:50: Patient admitted as a transfer from nursing home for blood transfusion related to anemia secondary to chronic kidney disease. Patient is typically on dialysis three times per week there. Patient oriented to room/unit safety and procedures. Orders: Order Name Order Status Timing Frequency Ordered On Note Weight measurement Pending Stat cont. 7/31/2024 12:55 Daily weight in the am related to chronic kidney disease Admission Discontinued Routine x1 7/31/2024 12:55 Admit to medical surgical unit for blood transfusion related to anemia secondary to chronic kidney failure Hemodialysis, arteriovenous access Pending Routine x1 7/31/2024 12:55 Hemodialysis three times a week Vital signs per floor routine Pending Routine x1 7/31/2024 12:55 Low sodium diet Pending Routine cont. 7/31/2024 12:55 Activity as tolerated Pending Routine x1 7/31/2024 12:55 Venipuncture Pending Routine x1 7/31/2024 12:55 Complete blood count (CBC) and comprehensive metabolic panel (CMP) in the am once. Blood and blood product transfusion Pending Stat x1 7/31/2024 12:55 Type and Cross once now to transfuse 2 units of PRBCs Intake and output assessment Pending Routine cont. 7/31/2024 12:55 Strict I/O RBC 2 units 2 units IV Pending Scheduled x1 7/31/2024 12:55 2 units packed red blood cells once now. Furosemide 40 mg PO Pending Scheduled q24h 7/31/2024 12:55 Vitamin B12 0.5 ml SQ Pending Scheduled x1 7/31/2024 12:55 Multivitamin 1 pill PO Pending Scheduled q24h 7/31/2024 12:55 Ferrous sulfate 325 mg PO Pending Scheduled q24h 7/31/2024 12:55 epoetin alfa 4000 units IV Pending Scheduled q72h 7/31/2024 12:55 Intake / Output Intake Oral Intake (mL) 120 mL Hourly Intake Totals 120 mL Intake Total (All): 120 mL Output Urine (mL) 60 mL Hourly Output Totals 60 mL Output Total (All): 60 mL Balance (Intake – Output): +60 mL Labs: NONE Assessments: Vitals Signs: B/P: 130/80 HR: 78 RR: 20 SpO2: 98% Room Air Temp: 98 F Pain: 0/10 NEURO: Orientation: A&O X4 Strength: Weak Movement Upon Request LUE, RUE, LLE, RLE Pupils (Both Eyes): Size: 4 Reaction: Round Brisk Accommodation Hearing: Intact Behavioral/Emotional: Calm Cooperative Glasgow Coma Score: Eye Opening: Spontaneous Motor Response: Obeys Verbal Command Verbal Response: Oriented X 3 CARDIO: Heart Tones: S1,S2 Regular Pulses: +1 ALL Cap Refill: < 3 Sec - ALL Skin Color & Description: Appropriate for ethnicity Dry Warm Intact Edema: Trace - LUE, RUE Non-Pitting - LUE, RUE Respiratory: Sputum: None Respiratory Symptoms: None Breath Sounds: Clear in all lobes Respirations: Regular GI: Abdominal Description (All Quads): Flat Soft GI Symptoms: None Bowel Sounds: Present in all quads Diet Tolerance: Good Stool: Soft Diet Type: Low Sodium GU: Urinary Symptoms: Oliguria Urine Color: Amber Urine Character: Clear Urinary Elimination: Dialysis Musculoskeletal: Symptoms: None Muscle Tone / Strength: Normal Strength - All Weight Bearing / Gait / Posture: Steady Dependent Mental Health: Behavior / Affect: Appropriate Stressors: Condition Hospitalization Diagnosis Coping: Well Consult: Social Work Integumentary: Skin Assessment 12:46 Clean, Dry, Intact Braden Scale: Total Score: At Risk 18 Vascular Access: Peripheral IV Right Forearm 20 gauge Transparent Dressing w/ securement device in place AV Fistula: Left Upper Arm Gauze wrapped around site s/p dialysis. +bruit; +thrill Activities of Daily Living (ADL) Morse Fall Risk: Total Score = 75 High Risk Plan of Care: Risk for Imbalanced Fluid Volume: Expected Outcomes: The patient will have normal laboratory values. Bathing Self-Care Deficit: Expected Outcomes: The patient or family will perform proper hygiene practices. QUESTION: Based on your identified clinical manifestations, what possible disease processes or problems exist? Provide at least two (2) problems and the clinical manifestations from above that support each of the individual problems/diagnoses. State which of the two is the priority in this case

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