E/M Coding Rounds Case of the Week: 6/10/08

A hospital progress note for a patient with CKD

CC:  Follow-up chronic kidney disease.

INTERVAL HISTORY:  The patient's chronic kidney disease remains stable. His HTN has been well controlled.


REVIEW OF SYSTEMS: GU: Negative for flank pain, hematuria or obstructinve symtoms.


PHYSICAL EXAMINATION:  GENERAL:  She is awake and alert, in no acute distress.  VITAL SIGNS:  Blood pressure is 121/69, respirations 20, pulse 85.  NECK:  Supple; no JVD.  LUNGS:  Clear bilaterallyt.  CARDIOVASCULAR:  Regular rate and rhythm.  ABDOMEN: Soft..  EXTREMITIES:  Show no peripheral edema. 


LABORATORY INFORMATION:  Shows a BUN of 24 with a creatinine of 1.3, potassium 4.1, hemoglobin of 10.1. 


IMPRESSION:

1. Chronic kidney disease, which is stable.
2. HTN, which is well controlled.
3. Multi-factorial, improving anemia.
4. DM with good glycemic control.
5. CAD s/p CABG.

PLAN:

1. Continue Procrit.
2. Continue current BP medications unchanged.
3. Continue to monitor electrolytes, fluid balance and renal function while in house.