BLUE LUTTOS HOSPITAL

Patient Profile
Name: George P. Oh Gender: Male Date: Feb. 10, 2021 Time: 6:30 pm
Age: 54 Years Old Ethnicity: Filipino Occupation: Taxi Driver
Address: Madapo Hills, Davao City Civil Status: Married
Height: 170 cm Weight: 60 kg
Chief Complaint:

 Shortness of breath
 Poor appetite
 Nausea and Vomiting
 Weakness
 Chest pain
 Itching
 Trouble sleeping
Medical History

 Hypertensive
Family History

 Hypertensive Mother
 Father died due to kidney disease
Social History

 Alcoholic and smoker

Vital signs:
Temperature: 36.5 C
BP: 140/90
RR: 20
PR: 80
O2 Sat. 99%
Physical Assessment
Appearance:
  Pallor
 Drowsy
Head & Eyes

 No lumps or tenderness
 swelling around the eyes
Skin:
- Dry skin
Edema (+):
- Legs, ankles, face

LABORATORY TEST ABNORMAL NORMAL

Blood urea nitrogen (BUN) test  28 mg / dlL  7-20 mg / dL
Serum Creatinine Test  1.6 mg / dL  1.4 mg / dL
Glomerular Filtration  15 ml / min  60 or more ml/min
Urine Test
 Protein  Positive  Negative
 Albumin (Albuminuria)  300 ml / L  Less than 30 ml/L
CT Scan

Medical Condition:

 Chronic Kidney Failure

REFERRAL
PHYSICIAN: DR. MITCHIE M. DELA CRUZ SPECIALTY: NEPHROLOGIST NUMBER: 09123456891
TREATMENT PLAN

 DIALYSIS
 KIDNEY TRANSPLANT