An outpatient consult for proteinuria...

REQUESTING PHYSICIAN: Richard Y. Hayes, MD

REASON FOR CONSULT: Proteinuria

HPI: I am seeing the patient at the request of Dr. Hayes for advice and opinion regarding proteinuria. 56 YOWM presents with persistent, moderately severe proteinuria which has been present for six months and has been associated with lower extremity edema.

PFSH: Remarkable for stable HTN, negative family history for hereditary renal disease and remote history of smoking.

ROS: CONSTITUTIONAL: No fevers, chills or weight loss. GU: Negative for gross hematuria, obstructive symptoms. CV: Negative for chest pain or orthopnea. GI: Negative for N/V/D or anorexia. MUSCULOSKELETAL: Negative for myalgias; positive for large joint pain associated with OA (but no NSAID consumption). SKIN: Negative for rash. All other systems reviewed and are negative.

CONSITUTIONAL: Awake and alert, well-nourished white male who appears stated age. BP: 146/80, RR 20, T 98.6. EYES: Anicteric sclerae; no lid-lag or proptosis. ENT: WNL. RESPIRATORY: Lungs CTA with normal respiratory effort. CARDIOVASCULAR: RRR, no MRGs; normal PMI. There is trace, symmetric bipedal edema. GI: Abdomen is soft, non-tender with no HSM. SKIN: Warm and dry; normal texture and turgor. No rash, lesions or ulcers. MUSCULOSKELETAL: Normal gait and station; No active tenosynovitis, joint swelling or tenderness.

Labs: BUN 23, creatinine 1.6, electrolytes normal. HGB 13.4. UA: 2 + protein, otherwise boring sediment. Protein/creatinine ratio is 755 mg/G.

IMPRESSION:

1. Significant, but non-nephrotic range proteinuria.
2. Sub-optimally controlled HTN with SBP of 146 and target of 130 mm HG.
3. Stage IIII CKD most likely due to benign hypertensive nephrosclerosis with estimated GFR of 47.46 mls/min.

PLAN:

1. Start LISINOPRIL 10 mg PO QD.
2. Renal U/S this week.
3. Patient was educated about current GFR and various stages of CKD.
4. Avoid NSAIDS and IV contrast if possible.
5. RTC in two months with renal profile, spot prot/creat ration and lipid panel.
6. Send copy of this note to Dr. Hayes.
7. Will continue to monitor the kidney function in conjunction with Dr. Hayes and address the modifiable risk factors to delay progression.