RENAL CONSULT NOTE 
******************** 
Reason for consult:
Consult requested by: 

year old patient with 
 

*Renal history: 
 

PAST MEDICAL HISTORY 
*************** 
1. 


ALLERGIES: 
********** 

MEDICATIONS: 
************ 
Home: 
Current: 

 
SOCIAL HISTORY 
************** 
Tobacco: 
Alcohol: 
Drugs: 
Employment: 

FAMILY HISTORY 
************** 
No family history of renal disease, DM, HTN, heart disease 

REVIEW OF SYSTEMS 
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*Const: No fever, weight loss, decreased oral intake. 
*HEENT: No visual complaints, oral lesions, epistaxis, hearing problems. 
*C.V.: No dyspnea, chest pain on exertion, syncope. 
*Resp: No cough, sputum, hemoptysis. 
*GI: No nausea, vomiting, diarrhea, abdominal pain, melena, BRBPR, jaundice. 
*GU: No dysuria, hematuria, foamy urine, calculi, recurrent infections. 
*MSS No joint pains. 
*Skin: No rash, pruritus. 
*Neuro: No seizure, stroke, headache, focal weakness, focal numbness. 
*Psychiatry: Well adjusted, no psychotic symptoms. 
*Endocrine: No thyroid problems 
*Heme/Lymph: No swollen nodes. 


PHYSICAL EXAMINATION 
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General: NAD 
BP: HR: RR=20 T= Height: Weight: 
I/O: 
Urine output/24h: 
EYES: Normal conjunctivae, normal pupil size
HEENT: Ears/nose normal. No oral lesions. 
NECK: No masses No thyromegaly JVP=
RESP:  Respiratory effort: normal, Ausc: normal
COR: Apex normal, Heart sounds normal 
ABD: No mass. No enlargement of liver or spleen
MSS: No joint deformity or effusion. Muscle strength normal 
SKIN: No rash No induration
LOWER EXTR: No edema, good pulses UPPER EXTR: No edema


DATA 
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CBC: 
Coags: 
Ca/Phos/Mg:
LFT: 
BMP: 
CXR:
Serologies: 
Urine: 
Renal U/S (): 



ASSESSMENT 
********** 
year old patient 

-eGFR by (MDRD, Cockroft-Gault) OR measured creatinine clearance by 24h urine collection 

 

RECOMMENDATIONS 
*************** 
1. 
2. 
3. 

 
_______________________________________________________
Nephrology Fellow 
Beeper 87362 
 
I have reviewed Dr.            's Hx, Exam and A/P. I have seen and examined the patient & the pertinent elements are: 

History:

Exam: 

Assessment and Plan: 


___________________________________________________
Nephrology Attending 

Milstein Allen
Area: Ward (50101)
ICD9: 
CPT-4: 9923