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------------------------------------------------ **Consultation Report**
**Date of Consultation:** 04/01/20XX
**Referring Physician:** X, MD
**Type of Consultation:** Nephrology
**Reason for Consultation:** Abnormal renal function
**History of Present Illness:**
The patient is a 67-year-old lady referred through the courtesy of Dr. M because of abnormal renal function. The patient has a history of hypertension, thyroid cancer, and recent status post-chemotherapy. She was admitted five days ago with vomiting and dehydration. The labs on admission revealed a BUN of 31 with a creatinine of 2.0, which has increased up to a BUN of 65 and a creatinine of 3.9. The patient has also had hypotensive episodes. This consultation was requested for the evaluation of her renal condition.
**Allergies:**
The patient is allergic to ACE inhibitors, penicillin, and sulfa drugs.
**Past Medical History:**
1. Hypertension
2. Atherosclerotic heart disease
*(Do not code atherosclerotic heart disease; there is no documented support as a current condition.)*
3. Hypothyroidism
*(Do not code hypothyroidism; there is no documented support as a current condition.)*
4. Thyroid cancer
**Social History:**
The patient denies smoking, alcohol use, and drug use.
**Family History:**
The family history is noncontributory.
**Physical Examination:**
- **Vital Signs:**
- BP: 109/50
- Pulse: 78 per minute
- Respirations: 18 per minute
- Temperature: 96.8
- **General:**
The patient is awake, alert, and oriented times three, not in any distress.
- **HEENT:**
Negative
- **Neck:**
The neck is supple. There is a positive mass in the anterior area of the neck.
- **Lungs:**
The lungs are clear to auscultation.
- **Heart:**
Normal S1 and S2
- **Abdomen:**
The abdomen is soft and non-tender. Bowel sounds are present and normal.
- **Extremities:**
There is no pitting edema.
- **Neurological:**
Normal
**Laboratory Data:**
The chemistry shows a sodium of 131, potassium of 3.9, chloride of 92, CO2 of 23, glucose of 84, calcium of 7.9, BUN of 65, and creatinine of 3.8. The CBC has a white blood cell count of 6.4, hemoglobin of 10.3, hematocrit of 30.8, and platelet count of 122,000.
**Impression:**
1. Chronic kidney disease, stage 3 (Primary reason for visit is chronic kidney disease stage 3) with superimposed acute renal failure, likely secondary to over-diuresis as well as acute tubular necrosis due to hypotensive episodes.
2. Thyroid carcinoma. The patient still has a mass on the anterior neck. Will discuss having the thyroid and mass removed.
3. Hypertension (Hypertension and CKD have a presumed relationship. Report with a combination code.)
**Recommendations:**
1. Strict intake and output
2. Urinalysis with microscopic
3. Intravenous fluids at 60 mL per hour
4. Discontinue diuretics
5. Renal ultrasound
6. Hold antihypertensive medication for blood pressure equal to or less than 140/70
7. Continue current medication
I will follow the patient with you. Thank you very much for allowing me to participate in the management of this patient.
**Signed by:** X, MD
**What are the diagnosis codes?**
Enter an ICD-10-CM code for each space provided.
