How detailed is this visit.


True Blue
Best answers
use only the 1995 guidelines.

79 yr old male with h/o of CRF, CABG, seen today for f/u of renal failure. Denies any significant
complaints since last visit to this office.

There is no history of nausea or vomiting, chest pain or SOB. He does c/o pain in the left knee and is
going to see an orthopedic surgeon for possible knee replacement.

P/E: Vitals - 150/80, HR 74/min
HEENT - unremarkable
Neuro - unremarkable
CV - no increase in jugular venous distention
Lungs - clear - no rub
Abd - soft, non-distended
Ext - bilateral 1+ edema
LABS: BUN 78, Creat went up to 4.2 previous was 3.9. Na 139, K+ 4.8, Cl 105, CO2 -25, Glu 95, Ca
9.1, Phos 4.7, PTH has come down to 643 –was 747, Hg 11.6, Ht 34.9 and platelets 189.

IMPRESSION: CRF, h/o HTN, CABG and OA of left knee

PLAN: Continue present meds, including Hectorol at 2.5mcg TIW. RTO in 4 weeks time for f/u visit.
Ordered a CBC, BMP and an intact PTH level one week before next appt. Since renal function is slowly
getting worse, discussed dialysis again with pt and possible creation of AV fistula. Pt declined at present
time because he wants to get his knee fixed first and then have shunt placement. Pt. stable, not uremic
and there's no indication for immediate dialysis.

Follow-up questions:
• How detailed is the history?
• How extensive is the examination?
• How complex is the decision-making

Thank You