Good day Doctor

This is Faith Jane A. Parba

First Year IM Resident

Respectfully referring OPD patient for Admission

ALGONES, VERGINITA
68/F

Admitting Impression:
ANEMIA AND UREMIC GASTROPATHY SECONDARY TO CHORNIC KIDNEY
DISEASE STAGE V SECONDARY TO HYPERTENSIVE KIDNEY DISEASE, DIABETIC
KIDNEY DISEASE

CC: vomiting; body malaise

History of Present Illness:

The patient is known hypertensive for approximately 10 years and diabetic for approximately 4
years but poor compliance to her maintenance medications.
Two weeks prior to consult, the patient had episodes of vomiting of previously eaten food x 2
episodes/day. This was associated with exertional dyspnea and body malaise.
Sought consult at nearest hospital. Work up was done revealing Creatinine of 1497.80, advised
for HD but patient was not amenable. The patient was then given with the following meds:
Ketoanalogue, Sodium Bicarbonate, Ferrous Sulfate + Folic Acid, EPO, and Losartan.
Two days prior to consult, there was persistence of vomiting now associated with body
weakness, the patient had difficulty in ambulation. This prompted consult and advised for
admission.

Past Medical History: (+) HPN: On Losartan 50mg/tab, poor compliance;

(+) DM: unrecalled medicines
(-) BA
(-) History of PTB
Family History: (+) DM, (+) HPN, (-) BA
Personal Social History: non-smoker; non-alcoholic beverage smoker
COVID History: Unvaccinated; No history of COVID infection

Review of Systems:
(+) pallor
(+) cough
(+) bipedal edema

PHYSICAL EXAMINATION
Anicteric sclera, Pale palpebral conjunctiva, (+) dry lips and oral mucosa
Equal Chest Expansion, (+) bibasal crackles
AP, NRRR, no murmur
Soft, nontender abdomen,
Full Pulses, CRT<2 secs, (+) bipedal edema
Latest Laboratories:

(02/01/2023)
Creatinine: 1497.80
Sodium: 133.3
Potassium 3.62

CBC + PLT: Hemoglobin 82

Hematocrit 23.5
RBC Count 2.72
WBC Count 14.97
Neutrophil 92.2
Lymphocytes 4
Monocytes 3.4
Eosinophil 0.2
Basophil 0.2
Platelet Count 106

Chest Xray (02/01/2023)

Left Lower Lung Pneumonia

PLANS:
Plan is to admit the patient for initiation HD and correction of Anemia