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CLINICAL EXAMPLE 99254
 

 
Renal consult for patient admitted with CHF

Reason for consult : Evaluation and management of renal insufficiency

Requesting physician : John Doe, MD

HPI :The patient is a 75 year old female with a history of diabetes and hypertension diagnosed approximately 25 years ago.  She also has coronary artery disease and ischemic cardiomyopathy and was admitted for presumptive CHF exacerbation three days ago.  Renal consult is called today for renal insufficiency seen on routine labs.  Patient denies any known history of renal disease in the past.  Her CHF has improved with diuretic therapy.  She has no spontaneous complaints. 

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

PMH : per HPI, plus dyslipidemia and mild osteoarthritis

ROS
General - Positive for occasional fatigue, negative for fevers or chills
Cardiovascular - Positive mild orthopnea and fluctuating lower extremity edema, negative PND
GU - Negative for flank pain, hematuria, obstructive symptoms, exposure to neprhotoxins, or habitual NSAID consumption

All other systems were reviewed and are negative.

FH : Mother died at 46 in an MVA, father at 81 of “old age”.  She has two siblings with hypertension and two grown children in good health.  There is no history of hereditary renal disease and she has no first degree relatives on dialysis.

SH : Patient denies alcohol or tobacco abuse.  She lives with her husband of 35 years in a single family home.

Physical Exam

Vitals: 160/84, 88, 98.6
General appearance: NAD, conversant, well nourished female
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 45, creatinine 2.2; Albumin 4.1, K 4.1, C02 18, HGB 10.9, UA shows 2+ protein with an otherwise boring sediment

Assessment

1) Presumptive chronic renal insufficiency associated with diabetic nephropathy and/or hypertensive nephrosclerosis
2) Poorly controlled hypertension with SBP of 160 and target of 130 mmHg
3) Anemia of uncertain etiology
4) Mild metabolic acidosis

Plan

1) Start lisinopril 20 mg PO QD
2) Screening renal ultrasound
3) Spot protein creatinine ratio to quantify protein excretion
4) Check iron stores with next blood draw
5) Start sodium bicarbonate tablets 650 mg PO BID
6) Patient was advised to avoid NSAIDs/COX-2 inhibitors and intravenous contrast if possible
7) Will make arrangements for outpatient follow-up to address the modifiable risk factors to delay progression of CKD

For a detailed breakdown of this note with tips and advice see  99254 E/M Insight

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