Sample Type / Medical Specialty: Consult - History and Phy.
Sample Name: Renal Insufficiency - Consult
Patient with a history of coronary artery disease, congestive heart failure, COPD, hypertension, and renal insufficiency.
(Medical Transcription Sample Report)
REASON FOR CONSULT:
Renal insufficiency.HISTORY OF PRESENT ILLNESS:
A 48-year-old African-American male with a history of coronary artery disease, COPD, congestive heart failure with EF of 20%-25%, hypertension, renal insufficiency, and recurrent episodes of hypertensive emergency, admitted secondary to shortness of breath and productive cough. The patient denies any chest pain, palpitations, syncope, or fever. Denied any urinary disturbances, difficulty, burning micturition, hematuria, or back pain. Nephrology is consulted regarding renal insufficiency.REVIEW OF SYSTEMS:
Reviewed entirely and negative except for HPI.PAST MEDICAL HISTORY:
Hypertension, congestive heart failure with ejection fraction of 20%-25% in December 2005, COPD, mild diffuse coronary artery disease, and renal insufficiency.ALLERGIES:
NO KNOWN DRUG ALLERGIES.MEDICATIONS:
Clonidine 0.3 p.o. q.8, aspirin 325 daily, hydralazine 100 q.8, Lipitor 20 at bedtime, Toprol XL 100 daily.FAMILY HISTORY:
The patient denies any alcohol, IV drug abuse, tobacco, or any recreational drugs.PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 180/110. Temperature 98.1. Pulse rate 60. Respiratory rate 23. O2 sat 95% on room air.
GENERAL: A 48-year-old African-American male in no acute distress.
HEENT: Pupils equal, round, and reactive to light and accommodation. No pallor or icterus.
NECK: No JVD, bruit, or lymphadenopathy.
HEART: S1 and S2, regular rate and rhythm, no murmurs, rubs, or gallops.
LUNGS: Clear. No wheezes or crackles.
ABDOMEN: Soft, nontender, nondistended, no organomegaly, bowel sounds present.
EXTREMITIES: No cyanosis, clubbing, or edema.
CNS: Exam is nonfocal.LABS:
WBC 7, H and H 13 and 40, platelets 330, PT 12, PTT 26, CO2 20, BUN 27, creatinine 3.1, cholesterol 174, BNP 973, troponin 0.18. Previous creatinine levels were 2.7 in December. Urine drug screen positive for cocaine.ASSESSMENT:
A 48-year-old African-American male with a history of coronary artery disease, congestive heart failure, COPD, hypertension, and renal insufficiency with:
1. Hypertensive emergency.
2. Acute on chronic renal failure.
3. Urine drug screen positive.
4. Question CHF versus COPD exacerbation.PLAN:
1. Most likely, renal insufficiency is a chronic problem. Hypertensive etiology worsened by the patient's chronic cocaine abuse.
2. Control blood pressure with medications as indicated. Hypertensive emergency most likely related to cocaine drug abuse.
Thank you for this consult. We will continue to follow the patient with you.
consult - history and phy., coronary artery disease, copd, congestive heart failure, hypertension, renal insufficiency, chronic renal failure, urine drug screen positive, urine drug screen, coronary artery, artery disease, insufficiency, hypertensive, heart, renal,
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