Medical Specialty:
Nephrology
Sample Name: Kidney Transplant - Followup
Description: Status post cadaveric kidney transplant with stable function.
(Medical Transcription Sample Report)
REASON FOR VISIT: Kidney transplant.
HISTORY OF PRESENT ILLNESS: The patient is a 52-year-old gentleman with ESRD secondary to hypertension, status post kidney transplant in February 2006. He had to back down on his WelChol because of increased backache. He actually increased his Pravachol and is tolerating this with minimal problems. He comes in for followup.
ALLERGIES: Aspirin and Altace caused cough, Lipitor and Pravachol at higher doses caused myalgias, Zetia caused myalgias.
MEDICATIONS: Gengraf 125/50 mg daily, CellCept 500 mg q.i.d., acyclovir 800 mg q.i.d., DexFol daily, ferrous sulfate Mondays, Wednesdays and Fridays, metoprolol 50 mg b.i.d., vitamin C daily, baby aspirin 81 mg daily, Bactrim Single Strength daily, Cozaar 50 mg daily, WelChol 625 mg daily, and Pravachol 10 mg daily.
PAST MEDICAL HISTORY:
1. ESRD secondary to hypertension.
3. Gunshot wound in Southeast Asia.
4. Hyperlipidemia.
REVIEW OF SYSTEMS: Cardiovascular: No chest pain, dyspnea on exertion, orthopnea, PND or edema. GU: No hematuria, foamy urine, pyuria, frequency or dysuria. He has occasional tingling over his graft, but this is not bothering him today.
PHYSICAL EXAMINATION: VITAL SIGNS: Pulse 82. Blood pressure is 108/64. Weight is 64.5 kg. GENERAL: He is in no apparent distress. HEART: Regular rate and rhythm. No murmurs, rubs or gallops. LUNGS: Clear bilaterally. ABDOMEN: Soft, nontender, and nondistended. Multiple scars. Right lower quadrant graft is unremarkable. EXTREMITIES: No edema.
LABORATORY DATA: Labs dated 07-11-06, hematocrit 34.8, sodium 137, magnesium 1.9, potassium 4.9, chloride 102, CO2 25, BUN is 37, creatinine is 1.3, calcium 10.1, phosphorus 3.7, and albumin 4.4. LFTs unremarkable. Cholesterol 221, triglycerides 104, HDL 42, LDL 158, and cyclosporine 163.
1. Status post cadaveric kidney transplant with stable function.
2. Hypertension under excellent control.
3. Hyperlipidemia not at goal. He simply is not tolerating higher doses of medications.
PLAN:
1. We will add over-the-counter fish oil b.i.d.
2. Continue all current medications.
3. Recheck labs today including urinalysis.
4. He will see transplant in two weeks and me in four weeks. We will plan to send urine for decoy cells on his next visit.
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