Nephrology Consult (general)

Nephrology Consult Note
Date: [date name="variable_1" default=""] [text name="variable_11111" default=""]
Referring MD: Dr. [text name="variable_3" default=""], [select name="variable_4" value="family doctor|nurse practitioner|emergency medicine MD|internal medicine|surgery"]
Family MD: Dr. [text name="variable_5" default=""]

Reason for consult:
[textarea name="variable_2345671" default=""]

ID:
[text name="variable_1006" default=""]-year-old [select name="variable_1007" value="male|female|undeclared/unknown/undetermined sex"] patient [text name="variable_1008" default=""]

Past medical history:
[checkbox name="PMH" value="CKD|Nephrolithiasis|DM2|DM1|Coronary artery disease|Peripheral vascular disease|Cerebrovascular disease|Hypertension|Atrial fibrillation|Valvulopathy|Heart failure|Dyslipidemia|Hypothyroidism|COPD|Asthma|OSA|Obesity|Benign prostatic hypertrophy|Gastroesophageal reflux disease|Peptic ulcer disease|Diverticulosis|Hepatosteatosis|Fatty liver disease|Liver cirrhosis|Hyperuricemia|Gout|Osteoarthritis|Osteoporosis|BPH|Depression|Anxiety"]
[textarea name="variable_1009" default=""]

Medications:
[textarea name="variable_10010" default="The medication list from DSQ was obtained and reviewed with the patient. Medication list attached at the end of this note."]

Allergies: 
[textarea name="variable_10011" default="No known allergies."]

History of present illness:
[textarea name="variable_10012" default=""] 

Review of systems:
[checklist name="variable_ros10013" value="Uremic symptoms such as anorexia, nausea, vomiting, pruritus, somnolence or confusion, weight loss, and an unpleasant taste in the mouth. |Recent episodes of chest pain or chest discomfort, shortness of breath on exertion, orthopnea, paroxysmal nocturnal dyspnea, or significant lower leg swelling. |Urine abnormalities such hematuria, pyuria, or foamy urine. |Passage of kidney stones. |Frequent UTIs. |New abdominal symptoms or lower urinary tract symptoms including dysuria, frequency or urgency, hesitancy, or incomplete voiding. |Frequent use of NSAIDs. The patient is well aware of the risks of NSAIDs and is avoiding these medications. |Recent imaging with intravenous radiocontrast. |Hemoptysis or ENT symptoms including epistaxis, sinus pain/discharge, or hearing loss. |Rashes or tender, swollen, or inflamed joints. |Risk factors for blood born illnesses such as hepatitis or HIV."]A further review of systems was unremarkable.

P/E:
* Vital Signs: BP: [text name="variable_12" default=""] HR: [text name="variable_8" default=""] RR: [text name="variable_9" default=""] SPO2: [text name="variable_10" default=""] on [text name="variable_11" default=""] TEMP: [text name="variable_7" default=""]
* Weight: [text name="variable_weight" default=""] Height: [text name="variable_height" default=""] 
* General Appearance: [select name="variable_109" value="NAD|Mildly distressed|Moderately distressed|Severely distressed|"], [select name="variable_13" value="well developed/well-nourished|underdeveloped/under-nourished|cachectic|"], [select name="variable_14" value="sitting comfortably on chair|lying comfortably in bed|sitting comfortably on bed|hunched over|"] [text name="variable_15" default=""]
* Head: [select name="variable_16" value="Normocephalic, atraumatic|"][select name="variable_17" value=", symmetrical face|, right facial droop|, left facial droop"] [text name="variable_18" default=""]
* Eyes: [select name="variable_22" value="Bilateral|Left|Right|"] [select name="variable_23" value="normal eyelids|retracted eyelid|ptosis|palpebral swelling|"]. [select name="variable_20" value="EOMI|Dysconjugate gaze|Strabismus|Horizontal nystagmus|Vertical nystagmus|Torsional nystagmus|Mixed nystagmus|4th n. palsy|6th n. palsy|"]. [select name="variable_19" value="PERRLA|Anisocoria|Fixed pupils|Unreactive to light only|Unreactive to accommodation only|"] [select name="variable_125" value="|bilaterally|on the left|on the right"]. [select name="variable_21" value="Conjunctiva clear|Conjunctival congestion|Conjunctival chemosis|Conjunctival exudates|Conjunctival icterus|Conjunctival pallor|Subconjunctival hemorrhage|"] [text name="variable_24" default=""]
* Oral: [select name="variable_41" value="Oropharynx clear|Erythematous oropharynx|Purulent oropharynx|"], [select name="variable_42" value="moist mucosa|dry mucosa|"], [select name="variable_43" value="normal colored oral mucosa|pale oral mucosa|cyanotic oral mucosa|"] [text name="variable_44" default=""]
* Heart: [select name="variable_52" value="Normal rate and rhythm|Tachycardiac|Bradycardiac|Small, weak pulse|Large bounding pulse|Bisferiens pulse|Pulsus alternans|Bigeminal pulse|Pulsus paradoxicus|"], [select name="variable_53" value="normal S1, S2|wide splitting|fixed splitting|paradoxical splitting|3rd heart sound|4th heart sound|"], [select name="variable_54" value="no murmurs, rubs, or gallops|early systolic murmur present|mid systolic (ejection) murmur present|late systolic murmur present|pan systolic murmur present|early diastolic murmur present|late diastolic mumrmur present|presystolic murmur present|continuous murmur present|pericardial rub present|gallop present|"] [text name="variable_110" default=""]
* Chest: [select name="variable_111" value="Clear to auscultation (normal vesicular breath sounds),|Bronchial breath sounds|Diminished breath sounds|Could not auscultate|"] [select name="variable_112" value="on bilateral|on right|on left|"] [select name="variable_55" value="lung fields,|upper lung field,|lower lung field,|"] [select name="variable_56" value="no wheezing|with wheezing|with stridor|"][select name="variable_57" value=", no crackles|, with crackles|"] [select name="variable_58" value="|on the left|on the right|on bilateral"] [select name="variable_59" value="|upper lung field|lower lung field|lung fields"] [text name="variable_60" default=""]
* Abdomen: [select name="variable_61" value="Normal bowel sounds|Hypoactive bowel sounds|Hyperactive bowel sounds|Absent bowel sounds|Could not auscultate|"], [select name="variable_62" value="not distended|distended|"], [select name="variable_63" value="not tender|with tenderness|"] on [select name="variable_64" value="all quadrants|upper right quadrant|upper left quadrant|lower right quadrant|lower left quadrant|"], [select name="variable_67" value="no masses|with a mass|"] [select name="variable_68" value="on all quadrants|on upper right quadrant|on upper left quadrant|on lower right quadrant|on lower left quadrant|"], [select name="variable_65" value="no hepatosplenomegaly|with hepatsplenomegaly|with hepatomegaly|with spenomegaly|"] [text name="variable_69" default=""]
* Extremities: [select name="variable_83" value="No significant deformity or joint abnormality.|With significant deformity or joint abnormality.|"] [select name="variable_84" value="No edema.|Edema +1.|Edema +2.|Edema +3.|Edema +4.|"] [text name="variable_85" default=""] [select name="variable_86" value="Peripheral pulses +3|Peripheral pulses +2|Peripheral pulses +1|Peripheral pulses +4|"]  [text name="variable_87" default=""]
* Musculoskeletal: [select name="variable_70" value="Normal muscle bulk|Decreased muscle bulk (atrophy)|"], [select name="variable_71" value="moves all limbs freely|limited range of motion|"], [select name="variable_72" value="no tenderness|with tenderness|"] [select name="variable_73" value="|on right|on left|on bilateral"] [select name="variable_74" value="on all limbs|upper limb|lower limb|shoulder joint|elbow joint|wrist joint|hip joint|knee joint|ankle joint|"], [select name="variable_78" value="no masses|with a mass|"] [select name="variable_79" value="|on right|on left|on bilateral"] [select name="variable_80" value="on all limbs|upper limb|lower limb|"]. [text name="variable_81" default=""] Muscle Strength: [select name="variable_121" value="5/5 on all limbs|"] [text name="variable_82" default=""]
* Neurological: [select name="variable_88" value="No focal neurological lesions.|Focal neurological lesion(s) present.|"] [text name="variable_89" default=""] [select name="variable_90" value="Cerebellar intact|Cerebellar defect(s) present|"] [text name="variable_91" default=""]
* Skin: [select name="variable_92" value="Normal color.|Jaundiced.|Cyanosed.|Vitiligo.|Other discoloration.|Hypopigmentation.|Hyperpigmentation.|"] [text name="variable_93" default=""] [text name="variable_93" default=""] [select name="variable_140" value="Warm|Hot|Cool|"], [select name="variable_141" value="dry|moist|"], [select name="variable_142" value="intact|non-intact"]. [text name="variable_143" default=""] [select name="variable_94" value="|Normal texture|Abnormal skin texure"] [text name="variable_95" default=""]

Urine output: [text name="variable_122222" default=""]

LABS, IMAGING, AND OTHER DIAGNOSTIC STUDIES: 

Labs: 
[textarea name="variable_10020" default="Please see lab data table attached."]
[textarea name="variable_100141" default="creatinine , GFR , bicarbonate , urinalysis , urine albumin to creatinine ratio, urine protein to creatinine ratio, Hb , transferrin saturation , ferritin , HbA1c , LDL , albumin , PTH"]


Microbiology: 
[textarea name="variable_111112" default="No recent pertinent microbiology data available."]

Imaging: 
[date name="variable_1" default=""] [select name="variable_1111116" value="No pertinent imaging studies available.|Ultrasound|CT scan C-|CT scan C+|MRI|Nuclear medicine scan|Abdominal XRay|Other"][text name="variable_109" default=""]
[textarea name="variable_1" default=""]

[date name="variable_1" default=""] [select name="variable_1111117" value="|Ultrasound|CT scan C-|CT scan C+|MRI|Nuclear medicine scan|Abdominal XRay|Other"][text name="variable_109" default=""]
[textarea name="variable_1" default=""]



IMPRESSION & PLAN:


[textarea name="variable_108" default=""]
Nephrology Consult Note
Date:
Referring MD: Dr. ,
Family MD: Dr.

Reason for consult:


ID:
-year-old patient

Past medical history:



Medications:


Allergies:


History of present illness:


Review of systems:
A further review of systems was unremarkable.

P/E:
* Vital Signs: BP: HR: RR: SPO2: on TEMP:
* Weight: Height:
* General Appearance: , ,
* Head:
* Eyes: . . .
* Oral: , ,
* Heart: , ,
* Chest:
* Abdomen: , , on , ,
* Extremities:
* Musculoskeletal: , , , . Muscle Strength:
* Neurological:
* Skin: , , .

Urine output:

LABS, IMAGING, AND OTHER DIAGNOSTIC STUDIES:

Labs:




Microbiology:


Imaging:








IMPRESSION & PLAN:


Result - Copy and paste this output:

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