Olignuria & Anuria HISTORY_LIST oliguria (< 20 ml/hr) anuria ( < 100 ml/day) foley catheter recent vomiting recent diarrhea diuretics nasogastric suction sweats from fever dysuria increased urgency flank pain abdominal pain fever chills dark urine bloody urine tenesmus INFECTIOUS DISEASES sepsis UTI bladder infection kidney infection CHRONIC DISEASES OR DISORDERS dehydration hemorrhage shock heart failure hypotension renal dz. BPH kidney stones bladder dz. SURGERY/PREVIOUS HOSPITALIZATIONS abdominal surgery bladder surgery renal surgery PREVIOUS TESTS UA UA with micro Electrolytes BUN Creatinine bladder ultrasound kidney ultrasound CT/MRI of abdomen TRAUMA OR INJURIES abdominal trauma SOCIAL HISTORY smoking alcohol caffeine illicit drugs - cocaine ALLERGY medications foods seasonal FAMILY HISTORY renal dz. renal malignancies MEDS_LAB_TESTS **** MEDS aminoglycosides neomycin amphotericin diuretics potassium **** LAB sodium electrolytes potassium BUN Creatinine UA UA with micro urine sodium urine osmolaliy urine creatinine **** TESTS bladder ultrasound kidney ultrasound 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 CHEST chronic coughing sputum production hemoptysis wheezing pneumonia bronchitis TB TB exposure SOB (altered by position?) edema chest pains pacemaker REVIEW_OF_SYSTEMS_2 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 morbilliform rash cyanosis jaundice cold clammy HEENT oral mucosa moist pooling of saliva under tongue enlarged tongue facial purpura atrophic tongue NECK neck veins flat JVD at 45: carotid pulse amplitude carotid pulse duration carotid bruits PHYSICAL_EVAL_2 CHEST rhonchi fine crackles course crackles wheezes dullness to percussion HEART regular rate & rhythm S3 gallop rubs murmurs ABDOMEN tenderness distention hepatomegaly hepatojugular reflex distended bladder costrovertebral angle tenderness nephromegaly RECTAL guaiac (occult blood) prostate enlarged prostate hard prostate tender prostate nodules PELVIC pelvic masses cyctocele urethrocele perineal sensation EXTREMITIES sacral edema pedal edema DIFF_DIAGNOSIS **** PRERENAL FAILURE volume depletion dehydration hemorrhage heart failure NSAIDS toxicity hepatorenal syndrome **** INTRINSIC ACUTE RENAL FAILURE nephrotoxins (aminoglycoside) acute tubular necrosis : hypotension shock vascular dz. glomerular dz. tubulointerstitial dz. **** POSTRENAL kidney stone obstruction BPH obstructed foley catheter spastic bladder anticholinergic medications