DOB: 03/02/1970

Bronte Crocker

DOB: 03/02/1970

57 YO female

Diagnosis: CKD

Admitted yesterday afternoon by Dr. Nephron Medical history:

CKD stage 3 and HTN, nil allergies

Social history:

Married, 3 young children, husband Barry works shift work

Family history:

Mother has HTN, fathes COPD

Maternal grandmother died from kidney failure

Medication history:

Ramipril 5mg OD orally

Metoprolol 25 mg BD orally

Current vital signs

Airway patent

Breaths RR 24 beats per minute spO2 94%. Shallow breathing

Circulation hart rate 72 BPM. BP 155/85

Warm to touch. Flushed face

Disability alert. GCS 15/15

E- Temp 36.8

Puffiness in patients legs and feet

Patient notices shortness of breath