Dialysis-related weakness
Complete SOAP example
Example narrative
61-year-old man from HOME, lives with partner and receives hemodialysis Monday/Wednesday/Friday, reports weakness and palpitations after missing today’s session because of vomiting. Last dialysis was three days ago.
Primary survey intact. Patient found seated on bed, alert, with no active fistula bleeding. Serial vitals and 12-lead obtained; generalized weakness without focal deficit. Medication list and dialysis centre information available.
Differential considerations: 1) electrolyte disturbance including hyperkalemia, 2) volume imbalance, 3) intercurrent gastrointestinal illness. Missed dialysis with cardiac symptoms.
Cardiac monitoring and serial reassessment continued. Care provided under applicable electrolyte/renal guideline as indicated. Transported promptly to ED with dialysis history, access details and last treatment included in handover.