DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: Kidney transplant evaluation.
HISTORY OF PRESENT ILLNESS: We had the pleasure of seeing this patient in the office today for evaluation for kidney transplant. The patient is a (XX)-year-old Hispanic lady with type 1 diabetes complicated by nephropathy, retinopathy, and neuropathy. She has been on dialysis since earlier this year; initially on peritoneal dialysis, but now has switched to hemodialysis because of issues with catheter placement. She has an AV fistula created in the right upper arm, which is not yet mature. She currently dialyzes via a tunnel catheter. She reports no problems with this. She did not have any infections whilst on peritoneal dialysis. She frequently runs high blood sugars but does not have an awareness of hypoglycemia. The patient has potential living donors in her husband and daughter and some other friends. Her blood type is AB.
PAST MEDICAL HISTORY: Type 1 diabetes, end-stage renal disease, hypertension, and hyperlipidemia.
FAMILY HISTORY: Positive for diabetes. Her sister has type 1 diabetes.
REVIEW OF SYSTEMS: The patient has some weakness and fatigue. She has numbness and aching in both lower extremities, which she attributes to her neuropathy. She has mild visual issues but has had laser therapy for retinopathy. She has no chest pain or shortness breath. She has no pain suggestive of claudication. She voids without difficulty.
CURRENT MEDICATIONS: Elavil 100 mg daily, Norvasc 5 mg daily, Coreg 25 mg daily, Lasix 20 mg daily, Novolin NPH 25 units in a.m. and 8 units in p.m., Novolin regular sliding scale, Zestril 40 mg twice a day, Prilosec 20 mg daily, and Crestor 20 mg daily.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: She is married with two children.
PHYSICAL EXAMINATION:
GENERAL: She is in no apparent distress. She is alert and oriented.
VITAL SIGNS: Her weight is 172 pounds and she is 5 feet 3 inches tall. Her blood pressure is 128/66. Heart rate is 88 and she is afebrile.
HEENT: Exam is normal.
NECK: Supple.
CHEST: Clear.
HEART: Heart sounds are normal.
ABDOMEN: Mildly obese. She has no incisions. No masses are felt.
EXTREMITIES: She has 1+ femoral pulses bilaterally. She has no peripheral lower extremity lesions.
ASSESSMENT AND PLAN: The patient has end-stage renal disease and type 1 diabetes. She is mildly overweight, but we see no other problems from a surgical standpoint. At this point, given that she is already on dialysis, a living donor kidney transplant would be the best option to get her transplanted as soon as possible. As she is a blood type AB, there should not be difficulty in finding a compatible donor. We discussed various aspects of transplantation with the patient and her husband, including living versus deceased. In future, she may be a candidate for pancreas after kidney transplant; however, we would like to see her body mass index drop below 30 prior to considering her for pancreas transplant. We did also discuss this with the patient and her husband.
Thank you for the opportunity to participate in this pleasant patient’s care.
