QC16 sunnie jing shen.docx - HISTORY PHYSICAL...

HISTORY & PHYSICAL EXAMINATION (NEPHROLOGY SERVICES)
Patient Name: Gilbert Tobias
Patient ID: 17-9582 DOB: 02/06/--- Age: 43 Sex: M
Date of Admission: 12/03
Admitting Physician: Phyllis Shelf, MD, Nephrology
PCP: N/A
Reason for Admission ： Elevated BUN and Creatinine
HISROTY AND PRESENT ILLNESS: This 43-year-old Hispanic man, new to the area with
medical history of significant for HTN, Type 2 diabetes Mellitus, ASCAD, diabetic
nephropathy, diabetic retinopathy, chronic kidney disease, stage 4-5. The patient previously
required hemodialysis three times weekly, his last hemodialysis on November 19th. The
patient stop to go to hemodialysis clinic after he moves from the area, he was told that his
renal function was not improving. Subsequently, hemodialysis was discontinued. Prior to
transferring care, he was noncompliant with his hemodialysis treatment appointment. The
patient is admitted this time after he falls. He was doing the car wash, his left knee give off,
and the patient fallen on his head. He started to have some upper back pain, neck pain and
headache. He was brought to the ED, the patient has history of right below knee amputation
and prostatic leg. On admission, the patient’s BP is elevated but now his BPs are improved.