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Eskanazi Clinic Dictation Note


686-7286
Author: 580365#
Dept: 89# (nephrology)
Worktype: 40# (initial visit), 41# (return visit)
MRN: xxxx#
Physician ID: 035162# (Moorthi), 063917# (Dollins), 499616 (Eadon)

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This is a nephrology clinic note for a patient  and MRN 
This is being dictated on behalf of Dr. M-o-o-r-t-h-i, physician id 035162
This is being dictated by Dr. D-e-a-n, dictation number 580365

Begin Dictation

NEPRROLOGY CLINIC NOTE:
DATE OF VISIT:

Mr/Ms xxxxx presents to nephrology clinic today for a regular scheduled followup appointment.
The patient was last seen on xxxxxx.
Since that time, they have been feeling well

xxxx

A 12-point review of systems was performed and was positive as dictated above. All other review of systems are negative

ACTIVE PROBLEMS: 
xxxxxx

CURRENT MEDICATIONS:
1. XXX

PHYSICAL EXAMINATION:
Vital Signs: Blood pressure XXX, pulse XXX, respiratory rate XXX, weight XXX
General: Alert and oriented, no acute distress, well-nourished, sitting comfortably in chair
HEENT: Pupils equal and round. No oral lesions. eyes are anicteric
Neck: No neck masses. No jugular venous distention (JVD), no thyromegaly.
Cardiovascular: Regular rate and rhythm with no murmurs or rubs. No JVD, no lower extremity edema
Respiratory: Clear to auscultation bilaterally without wheezes or crackles. Good air movement, non-labored breathing with no accessory muscle use.
Abdomen: Soft, nontender, not distended with normal bowel sounds.
Neurologic: Alert and oriented x3. Speech is clear and coherent. Face and limb movements are symmetric.
Dermatologic: No rashes.

LABORATORY DATA: 
Blood work obtained in clinic with the following results:


ASSESSMENT AND PLAN:

#) Chronic kidney disease. XXX
Stage 5/4/3, Cr=xxx, baseline Cr=xxx, baseline GFR=xxx
The possible original causes include: Diabetes, Hypertension. 

#) Hypertension. XXX.

- Continue current medications: 

#) Metabolic Bone Disease XXX.
Ca=xxx, (xxx when corrected for albumin=xxx), Phos=xxx
PTH=xxx
- Continue home medications: Calcitriol

#) Anemia of Chronic Renal Disease
Continue current medications


SUMMARY:
XXX

Eskanazi Clinic Note

NEPHROLOGY CLINIC NOTE:
DATE OF VISIT: 

is a xxx yo male with pmh Chronic Kidney Disease Stage 
who returns to nephrology clinic for a regular followup. Since he was last seen in clinic
He has been feeling well since his last clinic visit, and has had no hospitalizations or ER visits.

ER Visits or Hospitalizations:
NSAIDS:
Make Urine: 
Dizziness: 

REVIEW of SYSTEMS:
General: No fevers, no dizziness, no weakness, no fatigue
Cardiovascular: no chest pain, no palpitations, no edema
Pulmonary: no shortness of breath, no cough, no change in sputum production
Gastrointestinal: no nausea, no vomiting, no diarrhea, no constipation, no abdominal pain
Genitourinary: no nocturia, no dysuria, no urinary hesitancy, no hematuria, no partial voiding
Dermatologic: no rashes
All other review of systems are negative


ACTIVE PROBLEMS: 


CURRENT MEDICATIONS:


PHYSICAL EXAMINATION:
Vital Signs: Temp , Pulse , Blood pressure , SpO2 
General: Alert and oriented, no acute distress
HEENT: Pupils equal and round. No oral lesions. eyes are anicteric
Cardiovascular: Regular rhythm, no murmurs or rubs. No JVD, no lower extremity edema
Respiratory: Clear to auscultation bilaterally without wheezes or crackles. Good air movement, non-labored breathing
Abdomen: Soft, non-distended, non-tender, normal bowel sounds
Neurologic: No asterixis. Alert and oriented x3. Speech is clear and coherent. Face and limb movements are symmetric
Dermatologic: No rashes


LABORATORY DATA: Laboratory data and imaging was reviewed in the medical record.

ASSESSMENT AND PLAN:

#) Chronic kidney disease. Stage 
The original causes of the CKD are xxxxxx.
Today, serum Cr is xxxxx, which is within the range of approx xxxxx. 
His renal disease is stable with no signs of progression. 
Urine Prot/Cr ratio is xxxxx, suggesting approximately xxxx grams daily proteinuria. They are already on an ACE/ARB (Lisinopril).
Serum CO2 is stable at xxxx, so there is no indication for bicarbonate supplementation.
We will continue to control his renal disease by managing his risk factors, diabetes and hypertension.
She was counselled to avoid NSAIDs and IV Contrast

#) Hypertension
BP = 
The current regimen is 

#) Mineral Bone Disease
PTH 
Calcium and Phos are both stable and within normal limits.
Meds:

#) Anemia of Chronic Renal Disease
Hgb = xxxxx, no indication for ESA.
Meds: 


PLANS FOR NEXT CLINIC APPOINTMENT:


SUMMARY OF CHANGES IN THIS CLINIC APPOINTMENT:
- Return to clinic in 

Staff: Dr. Decker
Dawson Dean (312-1226)

Transplant Clinic Dictation Note


963-5520
Physician ID: 1621# (Mishler), 7871# (Sharfuddin)
Worktype: 1# (New patient), 2# (Return Patient)
MRN: xxxx#

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This is a nephrology clinic note for a patient  and MRN 
This is being dictated on behalf of Dr. M-i-s-h-l-e-r
This is being dictated by Dr. D-e-a-n, dictation number 580365

Begin Dictation


NEPRROLOGY POSTTRANSPLANT CLINIC NOTE:
DATE OF BIRTH: 
DATE OF VISIT:

Mr/Ms xxxxx presents to nephrology transplant clinic today for a regular scheduled followup appointment.
The patient was last seen on xxxxxx.
Since that time, they have been feeling well

xxxx

A 12-point review of systems was performed and was positive as dictated above. All other review of systems are negative

ACTIVE PROBLEMS: 
xxxxxx

CURRENT MEDICATIONS:
1. XXX

PHYSICAL EXAMINATION:
Vital Signs: Blood pressure XXX, pulse XXX, respiratory rate XXX, weight XXX
General: Alert and oriented, no acute distress, well-nourished, sitting comfortably in chair
HEENT: Pupils equal and round. No oral lesions. eyes are anicteric
Neck: No neck masses. No jugular venous distention (JVD), no thyromegaly.
Cardiovascular: Regular rate and rhythm with no murmurs or rubs. No JVD, no lower extremity edema
Respiratory: Clear to auscultation bilaterally without wheezes or crackles. Good air movement, non-labored breathing with no accessory muscle use.
Abdomen: Soft, nontender, not distended with normal bowel sounds.
Neurologic: Alert and oriented x3. Speech is clear and coherent. Face and limb movements are symmetric.
Dermatologic: No rashes.

LABORATORY DATA: 
Blood work obtained in clinic with the following results:

ASSESSMENT AND PLAN:

#) Chronic kidney disease. XXX
Stage 5/4/3, Cr=xxx, baseline Cr=xxx, baseline GFR=xxx
The possible original causes include: Diabetes, Hypertension. 

#) Hypertension. XXX.

- Continue current medications: 

#) Metabolic Bone Disease XXX.
Ca=xxx, (xxx when corrected for albumin=xxx), Phos=xxx
PTH=xxx
- Continue home medications: Calcitriol

#) Anemia of Chronic Renal Disease
Continue current medications


SUMMARY:
XXX

Discharge Summary


962-8401
Physician ID: 580365
Worktype and MRN: 03 <MRN>
Hospital: 11 (methodist), 22 (IU)
My Title: 3 (fellow)
Medical Specialty: 26

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This is a nephrology clinic note for a patient  and MRN 
This is being dictated on behalf of Dr. 
This is being dictated by Dr. D-e-a-n, dictation number 580365

Begin Dictation

MEDICINE DISCHARGE SUMMARY

DATE OF ADMISSION:
DATE OF DISCHARGE:
PRIMARY TEAM: 
STAFF PHYSICIAN:

CONSULTATIONS:

PROCEDURES:

IMAGING:

HISTORY OF PRESENT ILLNESS:


HOSPITAL COURSE:


#)
Continued to receive home medications xxxx and this was stable throughout the hospital stay.
Home medication xxxxx was initially held while xxxxx, but will be resumed on discharge.

ADMISSION PHYSICAL EXAM:

DISCHARGE PHYSICAL EXAM:

DISCHARGE MEDICATIONS:

START THESE NEW MEDICATIONS:

STOP THESE MEDICATIONS:

CHANGE THE DOSE OF THESE MEDICATIONS:


Continue all other previous home medications at their previous dose


DISCHARGE INSTRUCTIONS:
- Take all medications as prescribed
- Go to all scheduled followup appointments
- Follow a low fat and low salt diet

- Go to the nearest ER immediately if you have any of the following:
New chest pain or shortness of breath
Bleeding or severe bruising 
Confusion 
Increased or severe pain 
Blue lips or fingernails 

- Go to your primary doctor if you have any of the following:
Fever of 101 degrees or more 
Nausea or vomiting 
Constipation or diarrhea 
major weight loss or gain (more than 5 lbs in 1 week or more than 10 lbs in 1 month) 
More than normal mucous production, or yellow, green or smelly sputum

FOLLOWUP APPOINTMENTS:
- Primary Care Medicine within 1 week of hospital discharge

TESTS PENDING AT DISCHARGE: 
- None

Epic SmartPhrase for a clinic note

NEPHROLOGY CLINIC NOTE:

@M@ @LNAME@ is a @AGE@ @SEX@ with pmh Chronic Kidney Disease Stage xxx who returns to nephrology clinic for a regular followup. 

Since @HIS@ last clinic visit, @HE@ has been feeling well since his last clinic visit, with no hospitalizations or ER visits.

@CAPHE@ denies use of NSAIDS and has been compliant with all medications.


REVIEW of SYSTEMS:
General: No fevers, no dizziness, no weakness, no fatigue
Cardiovascular: no chest pain, no palpitations, no edema
Pulmonary: no shortness of breath, no cough, no change in sputum production
Gastrointestinal: no nausea, no vomiting, no diarrhea, no constipation, no abdominal pain
Genitourinary: no nocturia, no dysuria, no urinary hesitancy, no hematuria, no partial voiding
Dermatologic: no rashes
All other review of systems are negative


ACTIVE PROBLEMS: 
@PROB@ 

CURRENT MEDICATIONS:
@MEDSCURRENT@

ALLERGIES:
@ALLERGY@ 


PHYSICAL EXAMINATION:
Vital Signs:  @VS@ 
General: Alert and oriented, no acute distress
HEENT: Pupils equal and round. No oral lesions. eyes are anicteric
Cardiovascular: Regular rhythm, no murmurs or rubs. No JVD, no lower extremity edema
Respiratory: Clear to auscultation bilaterally without wheezes or crackles. Good air movement, non-labored breathing
Abdomen: Soft, non-distended, non-tender, normal bowel sounds
Neurologic: No asterixis. Alert and oriented x3. Speech is clear and coherent. Face and limb movements are symmetric
Dermatologic: No rashes


LABORATORY DATA: Laboratory data and imaging was reviewed in the medical record.

@LABBRIEF(NA:1,K:1,CL:1,CO2:1,BUN:1,CREATININE:1,GLU:1,GLUFASTING:1,ALB:1,TBILI:1,PROT:1,ALT:1,AST:1,ALP:1)@
@LABBRIEF(WBC:1,HGB:1,PLT:1,MCV:1)@


ASSESSMENT AND PLAN:

#) Chronic kidney disease. Stage 
The original causes of the CKD are xxxxxx.
Today, serum Cr is xxxxx, which is within the range of approx xxxxx. 
His renal disease is stable with no signs of progression. 
Urine Prot/Cr ratio is xxxxx, suggesting approximately xxxx grams daily proteinuria. They are already on an ACE/ARB (Lisinopril).
Serum CO2 is stable at xxxxx, so there is no indication for bicarbonate supplementation.
We will continue to control @HIS@ renal disease by managing risk factors including diabetes and hypertension.
@CAPHE@ was counselled to avoid NSAIDs and IV Contrast

#) Hypertension
BP = 
The current regimen is 

#) Mineral Bone Disease
PTH 
Calcium and Phos are both stable and within normal limits.
Meds:

#) Anemia of Chronic Renal Disease
Hgb = xxxxx, no indication for ESA.
Meds: 


PLANS FOR NEXT CLINIC APPOINTMENT:


SUMMARY OF CHANGES IN THIS CLINIC APPOINTMENT:
- Return to clinic in 

Staff: Dr. Decker
Dawson Dean (312-1226)

Epic SmartPhrase for an inpatient hospital note

SUBJECTIVE:
@M@ @LNAME@ is a @AGE@ @SEX@ who presented with


REVIEW of SYSTEMS:
General: No fevers, no dizziness, no weakness, no fatigue
Cardiovascular: no chest pain, no palpitations, no edema
Pulmonary: no shortness of breath, no cough, no change in sputum production
Gastrointestinal: no nausea, no vomiting, no diarrhea, no constipation, no abdominal pain
Genitourinary: no nocturia, no dysuria, no urinary hesitancy, no hematuria, no partial voiding
Dermatologic: no rashes
All other review of systems are negative


CURRENT MEDICATIONS:
@MEDS@

ALLERGIES:
@ALLERGY@ 


PHYSICAL EXAMINATION:
Vital Signs:  @VS@ 
General: Alert and oriented, no acute distress
HEENT: Pupils equal and round. No oral lesions. eyes are anicteric
Cardiovascular: Regular rhythm, no murmurs or rubs. No JVD, no lower extremity edema
Respiratory: Clear to auscultation bilaterally without wheezes or crackles. Good air movement, non-labored breathing
Abdomen: Soft, non-distended, non-tender, normal bowel sounds
Neurologic: No asterixis. Alert and oriented x3. Speech is clear and coherent. Face and limb movements are symmetric
Dermatologic: No rashes


LABORATORY DATA: Laboratory data and imaging was reviewed in the medical record.

@LABBRIEF(NA:1,K:1,CL:1,CO2:1,BUN:1,CREATININE:1,GLU:1,GLUFASTING:1,ALB:1,TBILI:1,PROT:1,ALT:1,AST:1,ALP:1)@
@LABBRIEF(WBC:1,HGB:1,PLT:1,MCV:1)@


ASSESSMENT AND PLAN: