Chronic Kidney Disease follow-up
Age: years old
Gender:
HISTORY:
Returns for a chronic kidney disease follow-up
Last visit was ago
Current symptoms:
,
, , , ,
Medications:
, , , , , , , ,
Adherence: ,
Smoking: , pack-years
Alcohol: , drinks per
Recreational drugs: ,
Caffeine: daily
Diet: , , , ,
Physical activity:
Weight: ,
Labs:
Creatinine:
GFR:
Na: , K:
Ca: , Mg: , Phosphate:
PTH: , Vitamine D:
Albumin:
Hb: , Ferritin: , B12:
HbA1c:
Lipids: , Cholesterol: , LDL: , HDL: , Triglycerides:
TSH:
Uric acid:
Microalbuminuria:
Urinalysis:
Vaccinations:
Pneumococcal:
Influenza:
Covid:
EXAM:
General appearance: ,
Vital signs: , BP , HR , RR , SpO2 %, Temp °
Metrics: weight: , height: cm, waist: cm, BMI:
Neck: , , , c-spine
Heart: , ,
Lungs: , ,
Abdomen: , , ,
Skin: on
Extremities: , , cap refill sec, pulses , ,
ASSESSMENT:
,
DDx: chronic kidney disease, acute kidney injury, chronic glomerulonephritis, polycystic kidney disease, diabetic nephropathy, hypertensive nephrosclerosis, interstitial nephritis, renal artery stenosis, renal vein thrombosis, amyloidosis, systemic lupus erythematosus, multiple myeloma, chronic urinary tract obstruction, nephrolithiasis, drug-induced nephropathy, heavy metal exposure, rhabdomyolysis, HIV-associated nephropathy
PLAN:
Investigations:
- Blood work: , , , , , , , , , , , , ,
- Urine: , ,
- Renal ultrasound
Treatments:
-
-
-
-
-
-
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- Dietary counseling: , , ,
- Blood pressure control
- Glycemic control
- Lipid control
- Smoking cessation
Further care:
- Referral to dietitian
- Referral to nephrologist
- Follow-up in
- Return if symptoms worsen or new symptoms develop such as swelling, shortness of breath, or decreased urine output
HISTORY: EXAM: ASSESSMENT: PLAN: