HPI: Patient complains of 12 hours of intermittent, exertional SOB associated
with lower extremity edema.
PFSH remarkable for ESRD for which the patient dialyzes thrice weekly and
HTN. Last dialysis was on Saturday. Negative history of tobacco abuse.
ROS: Constitutional: Negative for fever or chills. Cardiovascular: Negative for
chest pain, but positive for orthopnea. Pulmonary: Negative for hemoptysis or
cough. GI: Negative for N/V/D. All other systems reviewed and are negative.
EXAM: Moderate respiratory distress. BP 170/90, HR 84, RR 22. EYES: normal.
ENMT: somewhat poor dentition; otherwise normal. CV: RRR, no
MRGs. The patient has significant symmetric bipedal edema. Respiratory:Lungs have faint bibasilar rales. GI: abdomen soft, no HSM. Musculoskeletal:
Negative for digital clubbing. Psychiatric: A&OX3 with appropriate affect.
Data: BUN 74, creatinine 8.8, K 4.9, HGB 10.8, Troponin 0.01. I reviewed the
EKG which shows some LVH but no ST changes. I also reviewed the CXR
which showed moderate pulmonary vascular congestion, but no infiltrate.
Impression: New problem of pulmonary edema due to hypervolemia. No evidence
of acute MI or unstable angina. The patient also has ESRD which is stable
and poorly controlled HTN, which is most likely due to hypervolemia.
Plan: I spoke with the dialysis unit. We can get him in for an early treatment
this afternoon as opposed to having to wait for his usual shift tomorrow. For
that reason, okay to discharge him from the ER to go right over to the unit.
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