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CLINICAL EXAMPLE 99244
 

 
A patient referred to nephrologist for proteinuria

Reason for consult : Evaluation and management of proteinuria     

Requesting physician : John Doe, MD

HPI :The patient is a 65 year old male who referred for evaluation of proteinuria.  Last month he was found to have 2+ protein on routine UA.  As far as the patient knows, this is a new problem.  He denies any history of known renal disease in the past.  He has a history of essential hypertension which dates back at least 15 years, which he says has been easy to control on routine medications.  There is also a history of dyslipidemia which is stable on statin therapy and osteoarthritis in both knees which is controlled with Tylenol.

Medications
Atorvastatin 20 mg po qd
HCTZ 12.5 mg po qd
Amlodipine 10 mp po qd
Tylenol, prn

PMH : per HPI, plus a remote history of gout 10 years ago.

ROS  
A complete ROS was performed and documented.  Patient endorses occasional dyspnea on exertion as well as intermittent cluadication.  Pertinent negative findings included no history of obstructive symptoms, hematuria, flank pain, childhood kidney problems, habitual NSAID consumption, myalgias, or previous episodes of ARF.  For more details, please refer to today’s ROS form located on the chart.

FH : Mother died at 75 of MI, father at 81 of “old age”.  He has no siblings and three grown children all in good health.  There is no history of hereditary renal disease and he has no first degree relatives on dialysis.

SH : Patient drinks approximately two cocktails per day and is a non-smoker.  He lives with his wife of 35 years in a single family home.

Physical Exam

Vitals: 150/84, 88, 98.6
General appearance: NAD, conversant, well nourished white male
Eyes: anicteric sclerae, moist conjunctiva; PERRLA, fundi clear with sharp disc margins and normal posterior segments
HENT: AT/NC; oropharynx clear with moist mucous membranes and no mucosal ulcerations; normal hard and soft palate
Neck: Trachea midline; FROM, supple, no thyromegaly, lymphadenopathy or carotid bruits
Lungs: CTA, with normal respiratory effort and no intercostal retractions
CV: RRR, no MRGs
Abdomen: Soft, non-tender; no masses or HSM, no abdominal or femoral bruits
Extremities: No peripheral edema or extremity lymphadenopathy
Skin: Normal temperature, turgor and texture; no rash, ulcers or nodules; no levido reticularis
Psych: Appropriate affect, alert and oriented to person, place and time

Labs: BUN 25, creatinine 1.7; Albumin 4.1, K 4.1, C02 24, LDL 88, HGB 12, UA shows 2+ protein with an otherwise boring sediment

Assessment
  1. Proteinuria of uncertain etiology
  2. Sup-optimally controlled hypertension with SBP of 150 and target of 130 mmHg
  3. New diagnosis of stage 3 chronic kidney disease with an estimated GFR of 43 mls/min by the MDRD formula
Plan
  1. Start lisinopril 10 mg po qd
  2. Check 24 hour urine for protein and creatinine clearance
  3. Check spot protein/creatinine ratio
  4. Screening renal ultrasound
  5. Patient was advised to avoid NSAIDs and intravenous contrast if possible
  6. Return visit in six weeks
  7. Further work-up pending results of above
  8. Send a copy of this note to Dr. Doe

For a detailed breakdown of this note with tips and advice see    99244 E/M Insight

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