Consult - History and Phy.
Sample Name: End Stage Renal Disease - Consult
Description: Management of end-stage renal disease (ESRD), the patient on chronic hemodialysis, being admitted for chest pain.
(Medical Transcription Sample Report)
REASON FOR CONSULTATION: Management of end-stage renal disease (ESRD), the patient on chronic hemodialysis, being admitted for chest pain.
HISTORY OF PRESENT ILLNESS: This is a 66-year-old Native American gentleman, a patient of Dr. X, my associate, who has a past medical history of coronary artery disease, status post stent placement, admitted with chest pressure around 4 o'clock last night. He took some nitroglycerin tablets at home with no relief. He came to the ER. He is going to have a coronary angiogram done today by Dr. Y. I have seen this patient first time in the morning, approximately around the 4 o'clock. This is a late entry dictation. Presently lying in bed, but he feels fine. Denies any chest pain, shortness of breath, nausea, vomiting, abdominal pain, diarrhea. Denies hematuria, dysuria, or bright red blood per rectum.
PAST MEDICAL HISTORY:
1. Coronary artery disease, status post stent placement two years ago.
2. Diabetes mellitus for the last 12 years.
4. End-stage renal disease.
5. History of TIA in the past.
PAST SURGICAL HISTORY:
1. As mentioned above.
4. Right IJ PermaCath placement.
5. AV fistula graft in the right wrist.
PERSONAL AND SOCIAL HISTORY: He smoked 2 to 3 packets per day for at least last 10 years. He quit smoking roughly about 20 years ago. Occasional alcohol use.
ALLERGIES: No known drug allergies.
MEDICATIONS AT HOME: Metoprolol, Plavix, Rocaltrol, Lasix, Norvasc, Zocor, hydralazine, calcium carbonate, and loratadine.
GENERAL: He is alert, seems to be in no apparent distress.
VITAL SIGNS: Temperature 98.2, pulse 61, respiratory 20, and blood pressure 139/63.
HEENT: Atraumatic and normocephalic.
LUNGS: Clear to auscultation. Air entry bilateral equal.
HEART: S1 and S2. No pericardial rub.
ABDOMEN: Soft and nontender. Normal bowel sounds.
EXTREMITIES: No edema.
NEUROLOGIC: The patient is alert without focal deficit.
LABORATORY DATA: Laboratory data shows hemoglobin 13, hematocrit 38.4, sodium 130, potassium 4.2, chloride 96.5, carbonate 30, BUN 26, creatinine 6.03, and glucose 162.
1. End-stage renal disease, plan for dialysis today.
2. Diabetes mellitus.
3. Chest pain for coronary angiogram today.
4. Hypertension, blood pressure stable.
PLAN: Currently follow the patient. Dr. Z is going to assume the care.
Keywords: consult - history and phy., end-stage renal disease, esrd, hemodialysis, dialysis, angiogram, chronic hemodialysis, stent placement, coronary angiogram, diabetes mellitus, renal disease,