CKD.
Mr. David Miller, a 68-year-old male, presents with Stage 3 chronic kidney disease (CKD) secondary to hypertension and type 2 diabetes. His condition has been stable over the past three months, with no significant changes in symptoms. He denies any new onset of swelling, fatigue, or changes in urine output. He reports good adherence to his current medication regimen.
Relevant medical history includes a 15-year history of hypertension, managed with lisinopril, and a 10-year history of type 2 diabetes, managed with metformin. He also has a history of hyperlipidemia, treated with atorvastatin. There is no family history of kidney disease.
Current medications include:
* Lisinopril 20 mg orally once daily
* Metformin 1000 mg orally twice daily
* Atorvastatin 20 mg orally once daily
* Aspirin 81 mg orally once daily
Recent laboratory results:
* eGFR: 48 mL/min/1.73m² (October 28, 2024)
* Creatinine: 1.6 mg/dL (October 28, 2024)
* BUN: 28 mg/dL (October 28, 2024)
* Potassium: 4.5 mEq/L (October 28, 2024)
* Albuminuria: 150 mg/g creatinine (October 28, 2024)
* Hemoglobin: 13.5 g/dL (October 28, 2024)
No recent imaging studies have been performed.
Management plan includes:
* Dietary recommendations: Continue to follow a low-sodium, low-protein diet as advised by the dietitian.
* Fluid management: Maintain adequate hydration, aiming for 2-3 liters of fluid per day.
* Blood pressure control: Target blood pressure <130/80 mmHg. Continue lisinopril and monitor blood pressure at home.
* Glycemic control: Continue metformin and monitor blood glucose levels regularly. HbA1c goal is <7%.
* Anemia management: Monitor hemoglobin levels every three months.
* Bone mineral disorder management: Ensure adequate calcium and vitamin D intake.
Patient education provided regarding CKD progression, self-management strategies, warning signs, and the importance of adherence to treatment. The patient verbalized understanding of the information provided.
Follow-up appointment scheduled with the nephrologist in three months. Labs to be performed prior to the next visit include a complete metabolic panel, CBC, and urinalysis.
CKD.
[describe the patient's current chronic kidney disease status, including stage, underlying causes, and any recent changes in condition or symptoms] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.)
[detail the patient's relevant medical history, focusing on conditions that contribute to CKD or are impacted by it, such as hypertension, diabetes, cardiovascular disease, or autoimmune disorders] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.)
[list all current medications for CKD and associated conditions, including dosages, frequencies, and any recent adjustments or reported side effects] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a bulleted list.)
[summarize recent laboratory results relevant to CKD, such as eGFR, creatinine, BUN, electrolytes, albuminuria, and hemoglobin, including trends over time] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a bulleted list, including values and dates.)
[describe any imaging studies performed (e.g., renal ultrasound, CT scan) and their findings relevant to kidney structure or pathology] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.)
[document the current management plan for CKD, including dietary recommendations, fluid management, blood pressure control targets, glycemic control, anemia management, and bone mineral disorder management] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.)
[detail patient education provided regarding CKD progression, self-management strategies, warning signs, and the importance of adherence to treatment] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.)
[outline the plan for follow-up appointments, including frequency, type of specialist (e.g., nephrologist), and any specific labs or tests to be performed prior to the next visit] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences.)
(Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care - use only the transcript, contextual notes or clinical note as a reference for the information included in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes or clinical note, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or omit the placeholder completely.) (Use as many lines, paragraphs or bullet points, depending on the format, as needed to capture all the relevant information from the transcript.)