Clinical note · #37
Consultation
Patient: Thomas Reed
Age: 74
Place of Service: Office – Outpatient
Patient Status: New Patient
Insurance: Medicare (Traditional / Part B)
Referring Provider: Dr. L. Gomez (Primary Care)
Reason for Consultation: Evaluation and management recommendations for worsening chronic kidney disease.
Chief Complaint: Fatigue and leg swelling.
History of Present Illness (HPI):
The patient is a 74-year-old male referred by his primary care physician for nephrology consultation due to progressive worsening of chronic kidney disease. Recent laboratory studies demonstrate a steadily rising serum creatinine and declining estimated glomerular filtration rate (eGFR).
He reports increasing fatigue, decreased appetite, and bilateral lower-extremity swelling over the past several weeks. He denies chest pain, shortness of breath, nausea, vomiting, or recent hospitalizations. No prior nephrology evaluation has been performed.
Review of Systems (ROS):
- Constitutional: Fatigue, decreased appetite
- Renal: Decreased urine output
- Cardiovascular: Bilateral leg swelling
- Respiratory: Denies shortness of breath
- All other systems reviewed and negative
Past, Family, and Social History:
- PMH: Chronic kidney disease stage 4, hypertension, type 2 diabetes mellitus
- PSH: None significant
- FH: No known hereditary kidney disease
- SH: Former smoker; denies alcohol or illicit drug use
Physical Examination:
- General: Chronically ill-appearing elderly male
- Vital Signs: BP 154/88 mmHg, HR 82 bpm
- Cardiovascular: Regular rate and rhythm
- Extremities: 2+ bilateral pitting edema
Diagnostic Data Reviewed / Ordered:
- External laboratory results reviewed (elevated creatinine, declining eGFR)
- Additional labs ordered: CMP, urine protein-to-creatinine ratio
Assessment:
- Advanced chronic kidney disease (Stage 4)
- Hypertension
- Type 2 diabetes mellitus
Plan:
- Adjust antihypertensive regimen to optimize renal protection
- Discussed renal disease progression and prognosis with patient
- Initiate planning for potential renal replacement therapy
- Consultation report to be sent to referring provider