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Academic clinical discharge summary

Academic clinical discharge summary

 

AGACNP Discharge Summary

Patient Name: M. J.

Age: 85 years

Sex: Male

Admit Date: 02/06/23

Discharge date: 02/12/23

Reason for Admission:

  1. Acute Kidney Injury: (N17. 9). Administered Dopamine 0.35 mg since it promotes selective dilatation of the renal vasculature, which improves renal perfusion and reduces kidney damage. Dopamine also decreases sodium absorption, enhancing urine flow (Moore et al., 2018).
  2. Hyperkalemia (E87. 5): Resolved. Corrected w3ith Sodium bicarbonate 50mEq in 5% Dextrose to correct acidosis and hyperkalemia.
  3. Congestive Heart failure (I50. 9): Managed with Metoprolol 100 mg PO OD, Spironolactone 25mg PO OD, and Furosemide 40 mg PO.
  4. Hypertension (I10): Uncontrolled. The patient has been on Spironolactone 25mg and Vasotec 5 mg.
  5. Edema (R60. 9): Corrected with 40 mg/ml IV.

List of All Procedures:

  1. Urinalysis: RBCs- negative; WBCs- negative; Specific gravity-1.010
  2. Kidney function tests- BUN: Creatinine-24:1.6
  3. GFR-55mL/min
  4. Potassium assay- 5.9 mEq/L
  5. ABGs- pH- 7.30, HCO- 20 mEq/L, PaCo2– 32mmHg, PaO2-80

 

Consults during Hospitalization: The nephrologist was consulted to review the management of the patient for Acute Kidney Injury and prevention of complications.

 

Condition of Patient at Discharge:

The patient is alert and oriented and exhibits no signs of distress. His vital signs include: BP-136/90; HR-90; RR-18; Temp-98.4; SPO2-99%.

The respiratory symptoms have abated, and he reports improvement in the initial symptoms of chest pain, dyspnea on exertion, nocturnal dyspnea, and orthopnea. He shows no symptoms of respiratory distress. The lungs are clear on auscultation and percussion, and the rales and wheezes have diminished. The pitting edema on the lower limbs and jugular vein distention has alleviated. S1 and S2 are present on cardiovascular exam, and no gallop sounds or heart murmurs are present. The capillary re4fill time is 3 seconds. On genitourinary exam, the Urinary bladder is non-distended, with no masses, and non-tender on palpation. Potassium levels are at 4.8 mEq/L.

 

Discharge Medications:

 

  1. Furosemide 40 mg PO one daily. Furosemide is a loop diuretic recommended to correct fluid overload.
  2. Metoprolol 100 mg PO OD. This is a β-blockers indicated in Kidney injury to reduce sympathetic activation, which reduces the risk of acute renal damage and preserves renal function (Moore et al., 2018).
  3. Nifedipine 30 mg BD long-term dose; promote vasodilation and control BP (Moore et al., 2018).

 

Pending Test Results for Follow-Up: Urinary bladder Ultrasound to evaluate signs of obstruction in the urinary bladder and collecting ducts.

 

Discharge Instructions:

Medications: Stop Spironolactone to promote potassium elimination. Stop Vasotec since ACE inhibitors are nephrotoxic and cause Kidney failure. The patient will be instructed to avoid nephrotoxic agents like NSAIDs and ACEIs such as Vasotec and Captopril (Thongprayoon et al., 2020).

Diet: Restriction of dietary sodium, potassium, and fluids. This is vital in managing oliguric Acute Kidney Injury with hyperkalemia when the kidneys do not adequately excrete either toxins or fluids.

Weight monitoring: The patient will be instructed to weigh himself daily, keep a daily

log, and report any daily weight gain of more than 2 pounds immediately to the healthcare provider (Thongprayoon et al., 2020).

Follow-up: The patient will be scheduled for a follow-up after two weeks for evaluation of progress. He will be instructed to seek emergent care if he experiences worsening symptoms like breathlessness, chest pain, edema, and fatigue.

 

Discharge Follow-Ups: The patient may require hemodialysis if he develops: Hyperkalemia refractory to medical therapy; Uremia; BUN > 80-100; Severe acid-base disturbances due to medical therapy; Severe fluid volume overload that cannot be corrected with diuretics (Gameiro et al., 2020). The patient will be followed up every two weeks to assess if he has regained kidney function. If renal recovery is not observed within two weeks after discharge, he will be referred to a nephrologist.

 

Summary: The patient questioned whether his condition would progress to renal failure. He was informed that he would be followed up regularly with Kidney function and electrolyte tests in every check-up to assess kidney function and establish if there is an improved renal function (Gameiro et al., 2020). The patient also inquired about protein intake since patients with kidney failure are recommended to have a low-protein intake. This will need further exploration since patients with AKI have a high rate of protein breakdown. The increased metabolism and protein breakdown could be related to the stress of the illness.

 

Geriatric Considerations:

Management of AKI is similar for both elderly persons and younger patients. If the patient were younger, the priority interventions would still have been to correct fluid overload with furosemide, correct acidosis with bicarbonate administration, and correct hyperkalemia (Shen et al., 2021). However, many geriatric patients with AKI are usually too ill, or their appetite is too poor to eat adequate food. Nutritional support like total parenteral nutrition or hyperalimentation is usually provided for these patients. The aim of nutritional support in elderly patients with AKI is to provide sufficient nutrients to improve or maintain nutritional status, preserve lean body mass, restore and maintain fluid balance, and preserve kidney function (Shen et al., 2021).

 

 

 

References:

Gameiro, J., Fonseca, J. A., Outerelo, C., & Lopes, J. A. (2020). Acute Kidney Injury: From Diagnosis to Prevention and Treatment Strategies. Journal of clinical medicine, 9(6), 1704. https://doi.org/10.3390/jcm9061704

Moore, P. K., Hsu, R. K., & Liu, K. D. (2018). Management of Acute Kidney Injury: Core Curriculum 2018. American journal of kidney diseases: the official journal of the National Kidney Foundation, 72(1), 136–148. https://doi.org/10.1053/j.ajkd.2017.11.021

Shen, K. Y., Chuang, Y. C., & Tung, T. H. (2021). Clinical Knowledge Supported Acute Kidney Injury (AKI) Risk Assessment Model for Elderly Patients. International journal of environmental research and public health, 18(4), 1607. https://doi.org/10.3390/ijerph18041607

Thongprayoon, C., Hansrivijit, P., Kovvuru, K., Kanduri, S. R., Torres-Ortiz, A., Acharya, P., Gonzalez-Suarez, M. L., Kaewput, W., Bathini, T., & Cheungpasitporn, W. (2020). Diagnostics, Risk Factors, Treatment and Outcomes of Acute Kidney Injury in a New Paradigm. Journal of clinical medicine, 9(4), 1104. https://doi.org/10.3390/jcm9041104

 

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Important information on Writing a Discussion Question

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  • Follow APA-7th edition
  • Points will be deducted if the above is not followed

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