Nephrology Follow-Up Template

Chief Complaint

Nephrology Follow-Up Report

Template

Patient was reviewed in follow-up in person in the office on [date] for ongoing management of [pronoun] [Reason of visit]. Accompanied by [pronoun] [relationship of the patient, ex, spouse]. In-person appointments are now being reintroduced based on acuity and patient preference. Due to the COVID-19 pandemic, we are still providing the option of a virtual appointment. Medical History: [[List the patient's medical history in a structured format, including diagnoses, year of diagnosis, and any relevant details.] - [Condition 1] - [Year/Details] - [Condition 2] - [Year/Details] - ... Example: - CABG 2003 - VGH; Now on Apixaban - Dr. Gosal-Sadhra, Langley; PPM (Jan 2012) - Stage 3a A1 CKD - Type 2 Diabetes mellitus - Dx 2000 - Ozempic added - Hypertension - Dyslipidemia - Obstructive sleep apnea- Using CPAP - Thrombocytopenia - Dr. Szeto - No clear diagnosis on Bone Marrow Bx] Past Surgical History: [[List the patient's past surgical history in a structured format, including the type of surgery and year performed.] For example: - [Surgery 1] - [Year] - [Surgery 2] - [Year] - ... Example: - Hernia surgeries x 3 1966/1967/1990 - CABG surgery 2003; Pacemaker 2022] Clinical Update: [Provide a detailed summary of the patient's current & new diagnosis, including the type of cancer and any metastases. Describe the treatment regimen, specifying the medications, dosage cycles, and any relevant side effects or considerations related to the treatment. Include any expected physiological changes due to the medication and how these should be monitored.] [Summarize the patient's current health status, noting any new symptoms or lack thereof, such as nausea, vomiting, or dizziness. Include recent vital signs, particularly blood pressure readings, both in-office and at home, with specific dates and ranges. Mention any pain management strategies being used and their effectiveness.] Review of systems: • [List any respiratory symptoms the patient denies, such as dyspnea, chest discomfort, or lightheadedness; include any issues with peripheral edema.] • [Mention any long-term conditions the patient has, such as sleep apnea, and specify any treatments like CPAP.] • [Include any significant past medical events, such as remote CABG following myocardial infarction.] • [Note any absence of conditions, such as no history of peripheral vascular disease.] • [Record any procedures the patient underwent, such as colonoscopy/EGD, and note if records are unavailable.] • [Mention any conditions the patient denies, such as nephrolithiasis, gross hematuria, or urinary tract infections.] • [Include any medications the patient does not use, such as NSAIDs.] • [Describe any changes in energy level or fatigue, especially post-viral infection.] • [Note any musculoskeletal conditions the patient denies, such as osteoarthritis or joint pain.] Physical examination: [[If mentioned, provide a detailed summary of the patient's vital signs and physical examination findings. Include blood pressure readings, heart rate, weight, heart sounds, presence or absence of murmurs, evidence of peripheral edema, and lung field assessment. Use a narrative paragraph style to maintain consistency with the input content.] Example: In clinic today his blood pressure was 130/52 initially and then 126/47 on repeat. Heart rate 61 bpm. Weight 99.4 kg. Normal heart sounds with no murmur. No evidence of peripheral edema bilaterally. Lung fields were clear with normal breath sounds to bases bilaterally.] Current Medications: [List the patient's current medications, including the name, dosage, and frequency.] For example: - [Medication 1] - [Dosage] [Frequency] - [Medication 2] - [Dosage] [Frequency] Known Allergies: [List any known drug or other allergies. If none, state "None Known."] Investigations: Laboratory examination: [Summarize the laboratory findings, including urinalysis, serology, and other relevant tests. Do not include Urinalysis] For example: - SPEP/UPEP: [Details] - Serology: [Details] - [Other laboratory mentioned] Imaging: [Summarize any imaging results or note if imaging was not performed.] For example: - [Imaging Type]: [Details] Impression and Plan: [[For each condition, provide a detailed analysis including current status, recent changes, and any relevant lab results. Discuss any symptoms, medication adjustments, and management strategies. Include any instructions given to the patient regarding medication or lifestyle changes. If applicable, mention any consultations or requests for input from other healthcare providers.] [Condition 1: Detailed description of the condition, recent lab results, and any changes in treatment or management strategies. Include specific instructions given to the patient regarding medication adjustments or lifestyle changes.] [Condition 2: Detailed description of the condition, recent lab results, and any changes in treatment or management strategies. Include specific instructions given to the patient regarding medication adjustments or lifestyle changes. Mention any consultations or requests for input from other healthcare providers.] Example: 1. Stage G4 A2 chronic kidney disease: Renal function has decreased modestly from a GFR of 27 mL/min down to 19–20 mL/min which is consistent with decreased creatinine secretion on Palbociclib. This is further confirmed by lab work October 2 which showed improvement in GFR to 23 mL/min (decreased creatinine to 172) on lab work drawn during the 7 days off therapy. There is no evidence of volume overload and her blood pressures are well controlled on home measurements. Continue current medication. I discussed with her that I would have a low threshold to reduce the dose of Hydrochlorothiazide or discontinue it entirely if blood pressure is low or volume depletion is becoming an issue due to nausea and vomiting. I have instructed her to hold this medication it if she is experiencing nausea or vomiting with reduced intake, systolic blood pressure <110, or significant lightheadedness, until symptoms resolve. 2. Anemia profile: Hemoglobin has dropped to 94 g/L from 106g/L in July and then 102g/L in October. She is on very low-dose Aranesp 20 mcg q4 weekly. I have increased this to 20 mcg q2 weekly. I would request if Dr. Gagnon could please let me know if he has reconsidered to Ewing her on ESA therapy in the setting of metastatic breast cancer. Suspect she will require periodic transfusion if she is off Aranesp entirely. This is a very low dose of ESA and I think the risk of impact to her cancer is very low, but I would appreciate it if Dr. Gagnon could weigh in on that. ] Renoprotective measures: [[Provide a list of additional renal protective measures in bullet point. Include specific medications to avoid and conditions under which certain therapies should be held. Use a bulleted list format for clarity.] Example: • Avoid nonsteroidal anti-inflammatory medications • Hold ARB therapy and Metformin if acutely unwell with volume depletion, nausea, vomiting or significant diarrhea] PRESCRIPTIONS GIVEN: [[For each prescription, provide the medication name, formulation, dosage, route of administration, frequency, and duration. Use a bullet point list format to maintain clarity and consistency.] Example: • darbepoetin alfa in polysorbate 80 20 mcg/0.5 ml Injection Syringe (mL) 20 mcg Every 2 weeks X 3 Mth30] I have waitlisted [pronoun] for a nephrology follow-up appointment in [duration] time. Ongoing routine renal lab work has been arranged every [duration]. I would appreciate it if you could add me as a copy on [pronoun] standing order requisition. I will order additional renal lab work as indicated.