DATE OF VISIT: MM/DD/YYYY
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old lady who received a living-related kidney transplant four years ago in the setting of end-stage renal disease secondary to diabetic nephropathy. She is coming in here for reevaluation and management. She lives mainly overseas and she gets her blood work every three months there, and we see her here in the clinic every six months. She is generally doing well. The patient denies any urinary symptoms, shortness of breath, orthopnea or PND. Blood pressures at home have been ranging in the 120s to the 140s and she noted some lower extremity swelling.
MEDICATIONS: Norvasc 10 mg daily, aspirin 81 mg daily, insulin, Humulin N and Humulin R, metoprolol 100 mg p.o. b.i.d., CellCept 500 mg p.o. b.i.d., omeprazole 20 mg daily, prednisone 2.5 mg daily, tacrolimus 2 mg p.o. b.i.d., and Tylenol two tabs q. 6 hours p.r.n.
ALLERGIES: Listed in the chart.
REVIEW OF SYSTEMS: Per HPI. All other systems reviewed and are negative.
PHYSICAL EXAMINATION:
GENERAL: The patient does not appear in any distress.
VITAL SIGNS: Blood pressure 170/86, repeat was 148/84; pulse rate 84; respiratory rate 18; temperature 98.2; and weight 184 pounds with a BMI of 27.5.
GENERAL: The patient does not appear in any distress.
HEAD AND NECK: Atraumatic and normocephalic. No JVD.
CHEST: Good air entry bilaterally. No added sounds.
HEART: Normal S1 and S2 and no murmurs.
ABDOMEN: Soft and nontender.
LOWER EXTREMITIES: Positive for +2 edema. No clubbing or cyanosis.
LABORATORY DATA: Blood work from three days ago showed a white cell count of 5.8, hemoglobin 14.6, hematocrit 45.8, and platelet count 292,000. Sodium 138, potassium 4.2, chloride 106, bicarbonate 26, glucose 84, BUN 18, creatinine 0.84, phosphorus 4, calcium 9.6, magnesium 1.8, AST 18, ALT 18, total bilirubin 0.5, HDL is 42, LDL 98. Tacrolimus level 5.2 with a glycated hemoglobin of 7.8.
ASSESSMENT AND PLAN: This is a (XX)-year-old lady who is a recipient of a living-related kidney transplant, coming in for management.
1. Kidney transplant, living-related. She has been maintaining a stable graft function with a creatinine around 0.84. Her current immunosuppression seems to be adequate. We will continue her current immunosuppression. Her last tacrolimus level was 5.2 and is at target.
2. Hypertension. Blood pressure seems to be above target along with lower extremity edema. She will be a good candidate for a diuretic. We will add a hydrochlorothiazide of 12.5 mg p.o. daily. The other blood pressure medications that she is on include metoprolol and amlodipine with her history of diabetes along with a subnephrotic range of proteinuria detected last year. She will be a good candidate for an angiotensin-receptor blocker and we should consider the addition of a losartan and the weaning down off amlodipine in the coming next visit.
3. Subnephrotic range proteinuria. So far, she is not on any anti-proteinuric agents. We will send off for repeat spot urine, protein-creatinine ratio along with the UA today.
4. Diabetes. Her hemoglobin has improved from almost 12 to 7.8. She follows up regularly with Dr. John Doe. She does not seem to have any hypoglycemic unawareness.
