Patient Picture
Patient Information
Erin Watson
DOB:
10/31/1965
MRN:
843200
Weight:
160lb or 73kg
Admitting Diagnosis:
Peritonitis Secondary to Infected Tenkoff Catheter, Peritoneal Dialysis Catheter
Admitting Physician:
Johhanna Bach ER PA
Past Medical History
Allergies
None
Medical Problems
Chronic Kidney Disease Stage 4, Anemia, HTN, MI, Obesity, Hyperlipidemia, Heart Failure, Previous Smoker
Surgical History
CABG, Tenkoff Catheter Placement
Provider Notes
| Time | Provider | Notes |
|---|---|---|
| 0800 | Mary Rolland, RN | Assumed care of patient, patient AAOx4, patient oriented to room, hospital policies, and surroundings. Patient presents with abdominal pain that worsens with movement. Abdomen firm and distended, Tenkoff catheter site with erythema and purulent drainage noted. A few minutes after admission, patient developed chills, fever, and provider called to see patient. |
Vital Signs
| Time | 0700 | 0800 |
|---|---|---|
| Heart Rate | 90 | 113 |
| Blood Pressure | 110/60 | 88/50 |
| Respiratory Rate | 20 | 28 |
| Pulse Ox | 93% on Room Air | 90% on Room Air |
| Temperature | 99.0 F Oral | 101.1 F Oral |
| Pain | 10/10 | 10/10 |
Labs
Basic Metabolic Panel
| Lab Result | Tested Value | Normal Value Range |
|---|---|---|
| Glucose | 86 | 70-100 |
| BUN | 50 | 5-20 |
| Creatinine | 3.8 | 0.5-1.5 |
| Sodium | 135 | 135-145 |
| Potassium | 5.8 | 3.5-5.0 |
| Chloride | 95 | 95-105 |
| Calcium | 8.9 | 9-11 |
Complete Blood Count with Diff
| Lab Result | Tested Value | Normal Value Range |
|---|---|---|
| WBC | 17.4 | 4.8-10.8 |
| RBC | 2.0 | 4.7-6.1 |
| HGB | 9.8 | 12.6-17.4 |
| HCT | 27 | 37-51 |
| Platelets | 180 | 130-400 |