CAPD CYCLER DIALYSIS PROGRESS NOTE

question 65

Short Answer

CAPD CYCLER DIALYSIS PROGRESS NOTE
LOCATION: Inpatient, Hospital
PATIENT: Mandy Horton
ATTENDING PHYSICIAN: Ronald Green, MD
This patient was reasonably stable overnight. She was evaluated empty. She was in no cardiorespiratory distress. Clear lungs, dullness at the bases. A few crackles but otherwise a somewhat irregular heart rhythm this morning. Echocardiogram pending. Abdomen soft. Exit site okay. She was going to be put on CAPD today. This is being done to facilitate some of her studies as we can work this around them. CT is planned for this morning. The CT will be a critical study since we do have significantly abnormal liver function and the question is what could be possibly going on there. She has an esophagitis consistent with herpes or CMV, and the situation could turn ominous depending on the CT results. We are also doing a calorie count to see whether or not we need to consider supplementing her if everything else works out.
The dialysis plan today will be to use five 2.5-liter exchanges, three of them being 2.5% and two of them 1.5%. (MDM is moderate complexity.)
CPT Code: ____________________

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Definitions:

Formal Tone

A style of communication that is polite, restrained, and adheres to traditional standards and conventions.

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A manner of expression that uses mild or indirect words or phrases to describe a situation, event, or action, often to avoid causing offense or to mitigate the impact of harsh or blunt reality.

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