AAPC - Chapter 5 Practical Applications

CASE 1 Reason for consult: Acute renal failure (Indication for the visit.) HPI: The patient was followed in the past by my associate for CKD, with baseline creatinine of 1.8 two weeks ago. Found to have severe ARF this morning associated with acidosis and moderate hyperkalemia after presenting to the ER with complaint of dehydration. (These conditions were diagnosed by another physician in the emergency room.) The patient is admitted under observation status to the hospitalist service and the renal team is called for a consult. ROS: Cardiovascular: Negative for CP/PND. GI: Negative for nausea, positive for diarrhea. GU: Negative for obstructive symptoms or documented exposure to nephrotoxins. All other systems reviewed and are negative. PFSH: Negative family history of hereditary renal disease and negative history of tobacco or ETOH abuse. EXAM: Constitutional: 99/52, 18, 102. NAD. Conversant. Eyes: anicteric sc - N17.9, E86.0, N18.3, I95.9