How would a summary of the patient be written

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Question: How would a summary of the patient be written with the following information

Case Study: Ms. Anderson is a 76-year-old Caucasian female resident at a long-term carefacility. She was recently diagnosed with pulmonary fibrosis. She has a medical history of DM type 2,hypertension, CHF, Shingles (November 2020), and ESRD. She is widowed and has no children but has aniece in the area. She has a Scandinavian background, speaks English, and follows the Lutheran faith.She has an arteriovenous fistula for dialysis access in her left forearm and undergoes hemodialysis threetimes weekly at an outpatient dialysis center.Orders include:Blood sugar monitoring ACHS; call less than 75 or greater than 300Do not resuscitateLow protein, NAS diet1500ml/24 hours fluid restrictionDo not access arteriovenous fistulaDressing changes to fistula will be done at Dialysis centerApply pressure dressing and notify MD for bleeding at fistulaAmbulate independentlyOxygen @ 2L/NC PRNHold antihypertensive medications until after dialysis runMedication Include:Lisinopril 40 mg PO dailyMetoprolol 50 mg PO twice dailyFurosemide 40 mg PO BIDPotassium Chloride 20 meq PO TID daily with meals. Metformin 500 mg PO BID

 

Reference no: EM133357046

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