JMH – Nephrology – CKD Clinic Note

"NO OS DESESPEREIS QUE YA VIENE A NIVEL FELLOWSHIP - ESTE TEMPLATE ESTA AUN EN DRAFT"

--------- NEPHROLOGY Consult Opinion ---------

Home Phone: [text name="phone_1" default="000-000-0000"]
Other Phone: [text name="phone_2" default="000-000-0000"]
Pharmacy: [text name="pharmacy_1"]

REASON FOR CONSULT:
[textarea name="reason_consult_1" default="write the reason of consult"]

HPI PER ADMITTING RESIDENT NOTE:
[textarea name="HPI_admitting_1" default="copy and paste HPI from admitting resident"]

PMH:
[textarea name="pmh_1" default="CKD"]

PSH:
[textarea name="psh_1" default="no contributory"]

SOCIAL HX:
Employment: [text name="sh_1" default="no contributory"]
Alcohol: [text name="sh_2" default="denies"]
Tobacco: [text name="tobacco_1" default="denies"]
Drugs: [text name="drugs_1" default="denies"]

FAMILY HX:
[textarea name="fhx_1" default="no contributory"]

REVIEW OF SYSTEMS:
[checkbox name="ros_1" value="Constitutional: No fevers, changes in weight, fatigue, night sweats
|Head: No headache, sinus congestion or pain
|Ears: No ear pain, discharge, hearing loss, tinnitus, vertigo
|Eyes No changes in vision, eye pain, diplopia, photophobia
|Nose: No nasal discharge, coryza, sneezing, epistaxis
|Throat: No cough, sore throat, dysphagia, odynophagia
|Skin: No diagnosed skin conditions, new lesions, rashes, discoloration, dryness, hair changes
|Heme: No easy bruising, easy bleeding
|CV: No chest pain, palpitations, edema, presyncope, decrease in exercise tolerance
|Resp: No expectoration, dyspnea with rest or exertion, increased puffer use, orthopnea, PND, wheeze
|GI: No abdominal pain, nausea, vomiting, diarrhea, constipation, melena, appetite changes, dyspepsia, belching
|GU: No dysuria, frequency, urgency, hematuria, nocturia, incontinence, dribbling, hesitancy, retention, flank pain|Male: Denies discharge, lesions, testicular pain, hernias
|Female: Denies discharge, lesions, changes in dysmenorrhea, PMS, menstrual frequency, duration, flow, or symptoms
|MSK: No new weakness, arthralgias, myalgias
|Neuro: No weakness, confusion, numbness, dizziness, imbalance|Endocrine: No polydipsia, polyuria, heat/cold sensitivity"]

HOME MEDICATIONS:
[textarea name="home_meds_1" default="none"]

ALLERGIES:
[textarea name="allergies_1" default="NKDA"]

VITAL SIGNS:

PHYSICAL EXAM:
[select memo="<--- Select Exam" name="exam" value="General Adult Exam|General Male Exam|General Female Exam"]
[textarea cols=80 rows=2 default="GENERAL APPEARANCE: Well developed, well nourished, alert and cooperative, and appears to be in no acute distress."]
[textarea cols=80 rows=1 default="HEAD: normocephalic."]
[textarea cols=80 rows=1 default="EYES: PERRL, EOMI. Fundi normal, vision is grossly intact."]
[textarea cols=80 rows=1 default="EARS: External auditory canals and tympanic membranes clear, hearing grossly intact."]
[textarea cols=80 rows=1 default="NOSE: No nasal discharge."]
[textarea cols=80 rows=2 default="THROAT: Oral cavity and pharynx normal. No inflammation, swelling, exudate, or lesions. Teeth and gingiva in good general condition."]
[textarea cols=80 rows=1 default="NECK: Neck supple, non-tender without lymphadenopathy, masses or thyromegaly."]
[textarea cols=80 rows=3 default="CARDIAC: Normal S1 and S2. No S3, S4 or murmurs. Rhythm is regular. There is no peripheral edema, cyanosis or pallor. Extremities are warm and well perfused. Capillary refill is less than 2 seconds. No carotid bruits."]
[textarea cols=80 rows=2 default="LUNGS: Clear to auscultation and percussion without rales, rhonchi, wheezing or diminished breath sounds."]
[textarea cols=80 rows=2 default="ABDOMEN: Positive bowel sounds. Soft, nondistended, nontender. No guarding or rebound. No masses."]
[textarea cols=80 rows=2 default="MUSKULOSKELETAL: Adequately aligned spine. ROM intact spine and extremities. No joint erythema or tenderness. Normal muscular development. Normal gait."]
[textarea cols=80 rows=2 default="BACK: Examination of the spine reveals normal gait and posture, no spinal deformity, symmetry of spinal muscles, without tenderness, decreased range of motion or muscular spasm."]
[textarea cols=80 rows=2 default="EXTREMITIES: No significant deformity or joint abnormality. No edema. Peripheral pulses intact. No varicosities."]
[textarea cols=80 rows=5 default="LOWER EXTREMITY: Examination of both feet reveals all toes to be normal in size and symmetry, normal range of motion, normal sensation with distal capillary filling of less than 2 seconds without tenderness, swelling, discoloration, nodules, weakness or deformity; examination of both ankles, knees, legs, and hips reveals normal range of motion, normal sensation without tenderness, swelling, discoloration, crepitus, weakness or deformity."]
[textarea cols=80 rows=2 default="NEUROLOGICAL: CN II-XII grossly intact. Strength and sensation symmetric and intact throughout. Reflexes 2+ throughout. Cerebellar testing normal."]
[textarea cols=80 rows=1 default="SKIN: Skin normal color, texture and turgor with no lesions or eruptions."]
[textarea cols=80 rows=3 default="PSYCHIATRIC: The mental examination revealed the patient was oriented to person, place, and time. The patient was able to demonstrate good judgement and reason, without hallucinations, abnormal affect or abnormal behaviors during the examination. Patient is not suicidal."][conditional field="exam" condition="(exam).is('General Male Exam')"][textarea cols=80 rows=2 default="RECTAL: Good sphincter tone with no anal, perineal or rectal lesions. Prostate is not tender, enlarged, boggy, or nodular."][/conditional]
[conditional field="exam" condition="(exam).is('General Male Exam')"][textarea cols=80 rows=3 default="GENITALIA: Genital exam revealed normally developed male genitalia. No scrotal mass or tenderness, no hernias or inquinal lymphadenopathy. No perineal or perianal abnormalities are seen. No genital lesions or urethral discharge."][/conditional][conditional field="exam" condition="(exam).is('General Female Exam')"][textarea cols=80 rows=1 default="BREASTS: No masses, tenderness, asymmetry, nipple discharge or axillary lymphadenopathy."][/conditional]
[conditional field="exam" condition="(exam).is('General Female Exam')"][textarea cols=80 rows=3 default="PELVIC: Normally developed external female genitalia with no external lesions or eruptions. Vagina and cervix have no lesions, inflammation, discharge or tenderness. Cervix is nontender. Uterus is within normal limits with no adnexal fullness."][/conditional]

CURRENT MEDICATIONS:

****** DATA ******
CHEMESTRY:
Na [text name="Na_1"], K [text name="K_1"], Cl [text name="cl_1"], HCO3 [text name="hco3_1"]
Bun [text name="bun_1"], Cr [text name="QCreat"], BUN/Cr Ratio: [calc value="score4=(bun_1)/(QCreat)" memo="division"]
BUN/Creatinine is trending [select name="variable_1" value="up|down"]

Cockcroft-Gault formula for GFR estimate 
[select name="QGender" value="Male=1|Female=0.85"] <-- Gender
[text name="QAge"] <-- Age (in years)
[text name="QWeight"] <-- Weight (in kg)
Interpretation --> [calc value="score=((140 - (QAge)) * (QWeight) * (QGender) / ((QCreat) * 72));score>89.99?'CKD not present or CKD Stage I if microalbuminuria':score>59.99?'CKD Stage II':score>29.99?'CKD Stage III':score>14.99?'CKD Stage IV':'CKD Stage V'" memo="Interpretation"]
Based on estimated GFR of [calc value="score1=score.toFixed(2)" memo="GFR"] mL/min


ANEMIA EVAL:
Hbg [text name="hgb_1"], Plt [text name="plt_1"]
Ferritin [text name="ferritin_1"]/T Sat [text name="tsat_1"], B12 [text name="b12_1"]/Folate [text name="folate"], Smear [text name="smear_1"], Hapto/LDH
CKD MBD: Ca, Phos, PTH, 25 Vit D, Alk Phos
LFTs:
Coags: 
Lipids/a1c/serum albumin:   
Urine: UA with micro, Albuminuria , UPC
Serologies: ANA, dsDNA, C3/4, ANCA, ASO titer/anti-DNAse B, RF, anti-GBM, anti-PLA2R, HCV, HBsAg/Ab, HIV, SPEP/IFE/UPEP/FLc

Renal U/S: 
Size: R/L 
Echogenicity/Cortical thickness:
Cysts/masses
Hydro
PVR/bladder thickness

Renal Biopsy:


ASSESSMENT:
[textarea name="assessment_1" default="xx-year-old M/F with CKD stage"]

RECOMMENDATIONS:
-

D/w patient and primary team in detail.

Patient seen, examined, and case discussed with attending [select name="variable_ATTENDING" value="Dr. Rozas|Dr. Capitan Santana|Dr. Tamayo| Dr. Zapatin"]
[checkbox name="note_draft_1" value="** NOTE IS STILL IN DRAFT WILL UPDATE AFTER ROUNDS **"] [comment memo="Check if you want this text show up in output"]