Renal Insufficiency & Failure

HISTORY_LIST
oliguria (< 20 ml/hr)
anuria ( < 100 ml/day)
time of last void
diuretics
recent vomiting
recent diarrhea
recent hemorrhage
dyspnea
nausea
dysuria
flank pain
dark urine
bloody urine
peripheral edema
rashes
purpura
pregnant
new medications
INFECTIOUS DISEASES
sepsis
infections
vasculitis
UTI
glomerulonephritis
interstitial nephritis
CHRONIC DISEASES OR DISORDERS
diabetes
shock
anemia
heart failure
hypertension
hypotension
renal dz.
kidney stones
liver dz.
prostrate dz.
BPH
bladder dz.
ischemia
SURGERY/PREVIOUS HOSPITALIZATIONS
abdominal surgery
bladder surgery
renal surgery
PREVIOUS TESTS
UA
Electrolytes
BUN
Creatinine
CT/MRI of abdomen
bladder ultrasound
kidney ultrasound
TRAUMA OR INJURIES
abdominal trauma
SOCIAL HISTORY
smoking
alcohol
caffeine
illicit drugs - cocaine
ALLERGY
medications
foods
seasonal
FAMILY HISTORY
renal dz.
congenital renal abnormalities

MEDS_LAB_TESTS
**** MEDS
NSAIDS
contrast dyes
aminoglycosides
diuretics
**** LAB
sodium
potassium
calcium
phosphorus
electrolytes
BUN
Cr
UA
UA with micro
albumin
lipids
proteinuria
**** TESTS
ultasound bladder
ultrasound kidneys
CT/MRI of abdomen

REVIEW_OF_SYSTEMS_1
GENERAL
weight changes
appetite changes
anorexia
difficulty sleeping
fever
chills
polyphagia
hypophagia
changes in thirst
sleeping habit change
bowel habit change
fatigue
hypertension
previous physical exams
SKIN
pigmentation changes
texture changes
lesions
eruptions
pruritis
easy bruising
easy bleeding
unusual hair loss
changes in hair distribution
skin masses
finger/toe nail change
rashes
hives
striae
skin atrophy
uremic frost
hirsutism
plethora
neurofibromatosis lesion
HEENT
head trauma
skull fractures
head masses
hearing loss
vertigo
chronic ear infection
ear discharge
ear pain
hearing aid use
loss of vision
recent change in vision
photophobia
diplopia (double vision)
glaucoma
exudates
dry eyes
eye pain
cataracts
eye surgery
itchy eyes
excessive tearing
corrective lenses
nose bleeds
chronic sinusitis
nasal fractures
nasal drainage
polyps
changes in sense of smell
edentulous (without teeth)
partial plate
full plate
recent dental work
oral lesions
tonsillitis
strep throat
tongue problems
voice changes
chronic hoarseness
chronic halitosis
NECK
neck masses
enlarged thyroid gland
brachial cleft cysts
neck injury

REVIEW_OF_SYSTEMS_2
CHEST
chronic coughing
sputum production
hemoptysis
wheezing
pneumonia
bronchitis
TB
TB exposure
SOB (altered by position?)
edema
chest pains
pacemaker
HEART
MI
coronary artery disease
heart murmur
heart valve disease
left ventricular hypertrophy
mistral valve stenosis
pericarditis
palpitations
DOE
paroxysmal nocturnal dyspnea
orthopnea
edema
hypertension
rheumatic fever
cardiomyopathy
ectopic heart beats
arrhythmia
exercise intolerance
claudication
heart medications
ABDOMEN
abdominal pain
nausea
vomiting
diarrhea
constipation
hematochezia
hematemesis
hemorrhoids
GI x-rays
GI scopings
rectal bleeding
ulcers
bowel polyps
bowel incontinence
gall bladder disease
gall stones
hepatitis
cirrhosis
hepatomegaly
splenomegaly
GU
renal insufficiency
renal failure
dialysis
kidney stones
kidney disease
kidney cyst
flank pain
hematuria
pyuria
dysuria
chronic cystitis
nocturia
anuria
hesitancy
enuresis
change in urine color
prostatitis
epididymitis
scrotal problems
TURP
pain on intercourse
genital lesions
genital discharge

REVIEW_OF_SYSTEMS_3
OB/GYN
metorrhagia
menorrhagia
irregular menses
problems in pregnancy
use of contraception
breast masses
nipple discharge
breast skin changes
changes in axillary nodes
monthly breast exam
breast feeding children
EXTREMITIES
difficulty with gait
weakness
joint swelling
joint stiffness
muscle pain
muscle swelling
muscle injuries
sagittal plan scoliosis
coronal plane scoliosis
fractured bones
SLE
osteoarthritis
rheumatoid arthritis
fibromyalgia
NEURO
seizures
head injury
LOC
loss of coordination
difficulty in balance
sciatica
difficulty in fine motor skills
difficulty speaking
CVA (stroke)
weakness in arms
weakness in legs
tingling in legs and feet
tingling in arms
PSYCHIATRIC
depression
bipolar disorder
suicide attempts
psychiatric hospitalizations
personality disorders
ENDOCRINE
goiter
exophthalmos
dry skin
dry hair
intolerance to heat
intolerance to cold
changes in growth
sterility
impotence
decreased libido
LYMPHATIC AND HEMATOLOGICAL
lymphadenopathy
transfusion
anemia

PHYSICAL_EVAL_1
VITALS
BP
Pulse
Temp
GENERAL
alert
lethargic
cooperative
combative
no apparent distress
SKIN
turgor over sternal angle
sallow yellow complexion
fine white powder
cyanosis
jaundice
purpura
petechiae
spider angioma
NECK
neck veins distended

PHYSICAL_EVAL_2
CHEST
rhonchi
fine crackles
course crackles
regular rate & rhythm
S3 gallop
rubs
murmurs
pulsus paradoxus
displacement of heart border
muffled heart sounds
arrhythmias
ABDOMEN
tenderness
distention
hepatomegaly
hepatojugular reflex
distended bladder
suprapubic tenderness
costrovertebral angle tenderness
masses
ascites
RECTAL
guaiac (occult blood)
prostate enlarged
prostate hard
prostate tender
prostate nodules
NEURO
asterixis
myoclonus

DIFF_DIAGNOSIS
post-ischemic renal failure
nephrotoxic
prerenal azotemia
dehydration
renal artery occlusion
urinary obstruction
sepsis
malignant hypertension
acute glomerulonephritis
diabetic papillary necrosis
sickle cell dz. papillary necrosis
pregnancy preeclampsia
placental abruption
**** MEDS. & RENAL FAILURE
aminoglycosides
penicillins
cephalosporin
tetracyclines
vancomycin
rifampin
quinolones
sulfonamides
amphotericin
antineoplastics


