Nephrology New Consultation

Chief Complaint

Chronic Kidney Disease Consultation

Template

Thank you for your referral of this pleasant [age] year old [gender] for investigation and management of [pronoun] [Reason of the visit]. [Pronoun] was seen in the office with [pronoun] consent on [date]. In person appointments are now being offered to all patients, but due to the COVID-19 pandemic, I am still providing the option of a virtual consult via videoconference if preferred. Telephone consults are only being provided where there is no other feasible option at present. 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] History of presenting illness: [Provide a detailed narrative of the patient's chronic conditions, including the stage and setting of any diseases, typical and fluctuating measurements (e.g., EGFR, hemoglobin A1c), and current treatment regimens. Include information on blood pressure control and any absence of symptoms (e.g., albuminuria).] [Summarize any significant medical events in the past year, including procedures (e.g., bone marrow biopsy), therapies (e.g., physiotherapy for sciatica), and infections. Note the stability of renal function and any ongoing treatments or unresolved conditions.] 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.] 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."] Social History: [Provide details about the patient's social history, including smoking history, occupation, family support, alcohol use, and other relevant lifestyle factors.] For example: - Smoking History: [Details] - Occupation: [Details] - Family Support: [Details] - Alcohol Use: [Details] Lifestyle Notes: [Provide details about the patient's lifestyle, including caffeine intake, diet, and exercise habits.] For example: - Caffeine: [Details] - Diet: [Details] - Exercise: [Details] Physical examination: [[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.] Laboratory examination: [Summarize the laboratory findings, including urinalysis, serology, and other relevant tests.] For example: - Urinalysis: [Details] - SPEP/UPEP: [Details] - Serology: [Details] Imaging: [Summarize any imaging results or note if imaging was not performed.] For example: - [Imaging Type]: [Details] Impression and Plan: [Provide assessment of the patient's chronic conditions in a detailed narrative style, including stage and type, and any related comorbidities. Include information on cardiac function and any specialist follow-up. Describe the current management plan, including blood pressure targets and medications such as antihypertensives, anti-proteinuric therapy, and diabetes management drugs. Note any lifestyle modifications like exercise and diet. Conclude with an evaluation of the current treatment efficacy and any recommendations for changes or continuation of the current regimen.] Example: Patient has longstanding stage IIIa A1 chronic kidney disease in the setting of type 2 diabetes and coronary artery disease. Cardiac function is well preserved and he is followed by a cardiologist in the lower mainland. Blood pressure is well controlled to target of <130/80 on his current Antihypertensive regimen. He is on appropriate anti-proteinuric therapy with an ARB, SGLT2 inhibitor and Ozempic. Urine ACR is currently within normal limits. Hopefully diabetes will come under better control on Ozempic therapy. He exercises regularly and tries to follow a low-sodium diet. Overall his renal protective therapy is optimized and risk factors are appropriately managed. I do not have any further medication changes to recommend.] Other plan & management: • [Summarize potassium trends and any management recommendations. Note any specific reasons for higher potassium levels if applicable.] • [Detail iron deficiency status, including hemoglobin levels and any recent procedures like colonoscopy. Include recommendations for iron supplementation and any considerations due to chronic conditions.] • [Provide instructions for starting Ferrous fumarate, including dosage, frequency, and any additional recommendations for improving absorption.] • [Summarize bone mineral metabolism parameters, including PTH levels and recommendations for vitamin D3 supplementation.] • [Outline the current lab work schedule, including frequency and specific tests like urine ACR. Mention any additional lab work arrangements prior to appointments.] Additional renal protective measures include: [[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] I will see Patient in follow-up in [time in year or month]. If you have any concerns prior to the next appointment, please don't hesitate to contact my office. Thank you for involving me in this pleasant patient’s care.