QC16 sunnie jing shen.docx - HISTORY PHYSICAL EXAMINATION(NEPHROLOGY SERVICES Patient Name Gilbert Tobias Patient ID 17-9582 DOB 02\/06 Age 43 Sex M Date

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

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HISTORY & PHYSICAL EXAMINATION (NEPHROLOGY SERVICES)Patient Name: Gilbert TobiasPatient ID: 17-9582 DOB: 02/06/--- Age: 43 Sex: MDate of Admission: 12/03Admitting Physician: Phyllis Shelf, MD, NephrologyPCP: N/AReason for AdmissionElevated BUN and CreatinineHISROTY AND PRESENT ILLNESS: This 43-year-old Hispanic man, new to the area withmedical history of significant for HTN, Type 2 diabetes Mellitus, ASCAD, diabeticnephropathy, diabetic retinopathy, chronic kidney disease, stage 4-5. The patient previouslyrequired hemodialysis three times weekly, his last hemodialysis on November 19th. Thepatient stop to go to hemodialysis clinic after he moves from the area, he was told that hisrenal function was not improving. Subsequently, hemodialysis was discontinued. Prior totransferring care, he was noncompliant with his hemodialysis treatment appointment. Thepatient 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 andheadache. He was brought to the ED, the patient has history of right below knee amputationand prostatic leg. On admission, the patient’s BP is elevated but now his BPs are improved.
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  • Fall '17
  • Chronic kidney disease, BUN-to-creatinine ratio

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