Patient Profile
A.S. is a 70-year-old white woman who presented to the emergency department because of a 4-day history of increased shortness of breath and generalized weakness. A.S. stated that she has been able to do her daily chores at home independently, but for the last few days it was getting difficult for her to get around and that she needed to take frequent breaks because she was short of breath and had no energy. She has a long history of heart failure, diabetes mellitus type 2, and hypertension. She is admitted with a tentative diagnosis of acute kidney injury (AKI).
Subjective Data
Has been having headaches on and off, with nausea and dizziness
Reported that she hadn’t been taking her medications regularly at home because of "forgetfulness"
Has not been urinating a lot
Feels "puffy" in her legs and hands