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