Sample Name: Nephrology Consultation - 3
Description: Patient with end-stage renal disease secondary to hypertension, a reasonable candidate for a kidney transplantation.
(Medical Transcription Sample Report)
I had the pleasure of seeing the patient in the transplant clinic today. As you know, he is a 41-year-ole black male who was diagnosed with end-stage renal disease secondary to hypertension. He has been on hemodialysis since 02/2008. He is in my clinic for evaluation for cadaver kidney transplantation.
PAST MEDICAL/SURGICAL HISTORY: Briefly, his past medical history is significant for hypertension of more than 5 years, asthma, and he has been on Advair and albuterol. He was diagnosed with renal disease in 02/2008 and has since been on hemodialysis since 02/2008. His past surgical history is only significant for left AV fistula on the wrist done in 04/2008. He still has urine output. He has no history of blood transfusion.
PERSONAL AND SOCIAL HISTORY: He is a nonsmoker. He denies any alcohol. No illicit drugs. He used to work as the custodian at the nursing home, but now on disability since 03/2008. He is married with 2 sons, ages 5 and 17 years old.
FAMILY HISTORY: No similar illness in the family, except for hypertension in his one sister and his mom, who died at 61 years old of congestive heart failure. His father is 67 years old, currently alive with asthma. He also has one sister who has hypertension. The rest of the 6 siblings are alive and well.
ALLERGIES: No known drug allergies.
REVIEW OF SYSTEMS: Significant only for asthma. No history of chest pain normal MI. He has hypertension. He occasionally will develop colds especially with weather changes. GI: Negative. GU: Still making urine about 1-3 times per day. Musculoskeletal: Negative. Skin: He complains of dry skin. Neurologic: Negative. Psychiatry: Negative. Endocrine: Negative. Hematology: Negative.
PHYSICAL EXAMINATION: A pleasant 41-year-old African-American male who stands 5 feet 6 inches and weighs about 193 pounds. HEENT: Anicteric sclera, pink conjunctiva, no cervical lymphadenopathy. Chest: Equal chest expansion. Clear breath sounds. Heart: Distinct heart sounds, regular rhythm with no murmur. Abdomen: Soft, nontender, flabby, no organomegaly. Extremities: Poor peripheral pulses. No cyanosis and no edema.
ASSESSMENT AND PLAN: This is a 49-year old African-American male who was diagnosed with end-stage renal disease secondary to hypertension. He is on hemodialysis since 02/2008. Overall, I think that he is a reasonable candidate for a kidney transplantation and should undergo a complete pretransplant workup with pulmonary clearance because of his chronic asthma. Other than that, I think that he is a reasonable candidate for transplant.
I would like to thank you for allowing me to participate in the care of your patient. Please feel free to contact me if there are any questions regarding his case.
Keywords: nephrology, kidney transplantation, pretransplant, transplant clinic, renal disease, secondary, kidney, hemodialysis, renal, asthma, transplantation, hypertension,