History:     Chief Complaint: CKD PKD  HPI:  Charlene McDonald is a 52 y.o. female who returns for follow up of:  Stage III-IV CKD secondary to PKD.    Procardia  severe headaches; norvasc  didnt work after a few years;     Noticed very salt sensitive.     Drinks > 40 ounces of fluid per day.    Has abd fullnessseeing GI for EGD.  Increased fullness with meals.      Pt denies nausea, vomiting, MS change, fatigue, or bitter taste in mouth.    Patient has no dysuria, increased frequency, hematuria, or foamy urine.    Little less stress recently.  Son who is 27 years old has moved out of house as planned, living with girlfriend.      In January, BP high .  2 week ago, ER with BP 220/108 and txed with labetolol shots.  Had CT with hemangioma as in old imaging.      Labetolol 300 mg tid.  Diovan 40 mg daily.  Notices she is very salt sensitive.    Friend is asking for Tx # because she is willing to donate.  But pt has not given the # yet.    Bp was very high one time because forgot to take labetolol on time, so now knows to take on time.    Review Of Systems:   Complete ROS performed. All systems negative except as detailed in HPI or below.    PMH: history reviewed and without changes.  Patient  has a past medical history of Polycystic kidney disease; HEMANGIOMA; and Gout (12/15/2011).    Family History: Reviewed and without changes.  Patient family history includes Dialysis in her mother and Polycystic Kidney Disease in her mother, others, and son.    Social History: Reviewed and without changes.   She  reports that she has never smoked. She does not have any smokeless tobacco history on file. She reports that she does not drink alcohol or use illicit drugs. Her sexual activity history not on file.    Medications:  Medications - Previous to this Encounter   Medication Sig Dispense Refill   ? labetalol 100 mg Oral tablet Take 4 tablets by mouth every 8 hours.  360 tablet  5   ? calcium carbonate 600 mg (1,500 mg) Oral tablet Take 1 tablet by mouth 3 times a day with meals.  90 tablet  5   ? valsartan (DIOVAN) 40 mg Oral tablet Take 1 tablet by mouth daily.  30 tablet  11   ? cholecalciferol (VITAMIN D3) 1,000 unit Oral capsule Take 1,000 Units by mouth daily.  30 capsule  5   ? sodium bicarbonate 650 mg Oral Tab Take 1 tablet by mouth 3 times a day.  90 tablet  5   ? Simethicone 80 mg Oral Chew Take 1 Tab by mouth every 8 hours as needed for Gas.   90  5   ? Multivitamin Oral Tab take 1 tablet by oral route once daily with food  30  5         Physical Exam:     Multi-System Exam:  BP 180/110 | Pulse 78 | Ht 5 5 | Wt 72.576 kg (160 lb) | BMI 26.63 kg/m2  Body mass index is 26.63 kg/(m^2).       Physical Exam:  Constitutional: no acute distress and well developed/well nourished  Eyes: lids/conjuctiva normal, anicteric and normal exam  Ears/Nose/Mouth/Throat: oropharynx pink and dry mucous membranes.  Cardiovascular: normal s1, s2, no murmurs, no pericardial friction rub and no gallops  Respiratory: clear to auscultation bilaterally, no wheezing and no rales  Abdomen:  Normoactive bowel sounds, nontender, nondistended. No rebound or guarding.  + palpable kidneys.   Back: no costo-vertebral tenderness (CVAT)  Musculoskeletal: normal gait.  Tense trapezius muscles  Lower Extremity: no peripheral edema.   Neurologic: alert, awake and  oriented times three (AAand 0 x3), normal light touch sensation, normal strength and no asterixis  Lymphatic: no cervical nodes palpated  Psychiatric: normal mood/affect, non-anxious and normal judgement and insight  Skin: no rash      Medical Decision Making:     Data Review:    UREA NITROGEN   Date Value Range Status   1/2/2013 57* 10 - 30 MG/DL Final       CREATININE   Date Value Range Status   1/2/2013 5.59* 0.50 - 1.30 MG/DL Final       ALBUMIN   Date Value Range Status   1/2/2013 4.4  3.5 - 4.9 G/DL Final       CALCIUM   Date Value Range Status   1/2/2013 9.2  8.5 - 10.5 MG/DL Final      _       PHOSPHORUS   Date Value Range Status   12/26/2012 4.1  2.4 - 4.7 MG/DL Final       No results found for this basename: URICACID       MAGNESIUM   Date Value Range Status   5/19/2011 2.1  1.5 - 2.5 MG/DL Final      NOTE: As of 7/16/09 the new reference range for Age 0-10 is 1.5 to 2.5 mg/dl       GLUCOSE   Date Value Range Status   1/2/2013 81  65 - 139 MG/DL Final      NON-FASTING 65-139 mg/dL      FASTING 65 - 99 mg/dL       No components found with this basename: VITAMIND12       INTACT PARATHYROID HORMONE   Date Value Range Status   12/26/2012 201* 16 - 87 PG/ML Final       WHITE BLOOD CELL   Date Value Range Status   12/26/2012 4.3* 4.5 - 11.0 x10 3/uL Final       HEMOGLOBIN   Date Value Range Status   12/26/2012 10.1* 11.7 - 15.0 G/DL Final       No components found with this basename: HCT       PLATELET   Date Value Range Status   12/26/2012 199  150 - 450 x10 3/uL Final       No components found with this basename: PROCREA       No components found with this basename: IMMUNOFIXSER       No components found with this basename: IMMUNOFIXURI       No results found for this basename: C3       No results found for this basename: C4       No results found for this basename: ANAQUANT       HEPATITIS BS AG   Date Value Range Status   5/19/2011 NON-REACTIVE  NON-REACTIVE Final       HEPATITIS C VIRUS AB   Date Value Range Status   5/19/2011 NON-REACTIVE  NON-REACTIVE Final       No components found with this basename: CRYOGLOB       TSH   Date Value Range Status   12/26/2012 1.10  0.34 - 5.60 uIU/Ml Final      Reference Ranges:            Age:            Female:     Male:      1-25 days       1.5-6.5    0.7-9.8      1-24 months     1.6-5.7    0.7-5.9      9-10 years      0.9-4.0    1.0-3.7      11-14 years     0.7-3.4    0.8-3.9      15-17 years     0.6-3.7    0.7-2.8      18-99 years     0.34-5.60  0.34-5.60       No results found for this basename: ANCA         Laboratory:   Cr was 4.54    Assessment/Plan:  1. CKD (chronic kidney disease) stage 4, GFR 15-29 ml/min  URIC ACID-BLD, URINALYSIS, ROUTINE, VITAMIN D 1, 25-DIHYDROXY, VITAMIN D, 25-HYDROXY, CK(CPK)-BLD, UREA-URINE RANDOM, CBC+PLT+DIFF, COMP METABOLIC PANEL(AKA CMP), ELECTROLYTES-URINE, MICROALBUMIN-URINE RANDOM, CREATININE-URINE RANDOM, MICROALB/CREAT,URINE (RAND), PARATHYROID HORMONE INTACT IRMA, PHOSPHORUS-BLOOD, PROTEIN/CREA.RATIO,URINE   2. Anemia  VITAMIN B12 and  FOLATE-SERUM, FERRITIN, IRON, IRON + TIBC   3. Hypertension  LIPID PANEL   4. Fatigue  TSH       52 F with PKD, CKD IV, HTN, tension headaches.     HTN:    Goal BP < or = 130/80 for maximal renal preservation.  Pt feels she is salt sensitive, but has not increased salt intake.      Bp well controlled today.    D/w pt re: taking labetolol every 12 hours to avoid rebound HTN, to keep a few pills in her bag always.     CKD:  From PKD.   Pt now on wait list for kidney tx.  She does not have a potential living donor but friend is interested in work uppt has not given her the # yet.  Friend asked againencouraged work up early to see if she is a match so if needed, can do preemptive tx.    Discussed with patient to avoid NSAIDS, Fleets phosphosoda, iv contrast for CT or angiograms if possible (and re: use of N-acetylcysteine for prophylaxis if contrast is needed), given CKD.     Fatigue:Improved.     Anemia:  Check fe studies, vitamin b12, folate.     Gout:  Check uric acid, esr, crp.        F/u in3 months.                                        History:     Chief Complaint: CKD PKD  HPI:  Charlene McDonald is a 52 y.o. female who returns for follow up of:  Stage III-IV CKD secondary to PKD.    Procardia  severe headaches; norvasc  didnt work after a few years;     Noticed very salt sensitive.     Drinks > 40 ounces of fluid per day.    Abd painLeft side closer to the front. Lasted all night at about 10/10. Took 2 tylenol and now is 3-4 out of 10 pain. No dysuria, hematuria, no fevers. Likely, burst cyst from PKD. No gravel, hematuria, or radiation to groin,     May 13th had bad headache, and BP was 210. Gave her reglan and it helped the headache. BP 190s. Was anxious.     Yesterday, BP 150/100.     Saw Dr. Duddenpuddi who told her that her EKG was irregularcardiologist said it may have been related to the way she was breathing.   Weight 182, BP was 160. Took extra labetolol. Eating well, and on weight watcherlost 8 pounds over 6 weeks. Avg 150-160 now. When taking diovan 40 mg (instead of the prescribed 20 mg), BP can decrease to 140s.    H/o diverticulitis 4 years agowas in ER and  given fluids.   Has had granola bar with nuts and seeds over 4 weeks.     Review Of Systems:   Complete ROS performed. All systems negative except as detailed in HPI or below.    PMH: history reviewed and without changes.  Patient  has a past medical history of Polycystic kidney disease; HEMANGIOMA; and Gout (12/15/2011).    Family History: Reviewed and without changes.  Patient family history includes Dialysis in her mother and Polycystic Kidney Disease in her mother, others, and son.    Social History: Reviewed and without changes.   She  reports that she has never smoked. She does not have any smokeless tobacco history on file. She reports that she does not drink alcohol or use illicit drugs. Her sexual activity history not on file.    Medications:  Medications - Previous to this Encounter   Medication Sig Dispense Refill   ? labetalol 100 mg Oral tablet Take 4 tablets by mouth every 8 hours.  360 tablet  5   ? calcium carbonate 600 mg (1,500 mg) Oral tablet Take 1 tablet by mouth 3 times a day with meals.  90 tablet  5   ? valsartan (DIOVAN) 40 mg Oral tablet Take 1 tablet by mouth daily.  30 tablet  11   ? cholecalciferol (VITAMIN D3) 1,000 unit Oral capsule Take 1,000 Units by mouth daily.  30 capsule  5   ? sodium bicarbonate 650 mg Oral Tab Take 1 tablet by mouth 3 times a day.  90 tablet  5   ? Simethicone 80 mg Oral Chew Take 1 Tab by mouth every 8 hours as needed for Gas.   90  5   ? Multivitamin Oral Tab take 1 tablet by oral route once daily with food  30  5         Physical Exam:     Multi-System Exam:  BP 180/110 | Pulse 78 | Ht 5 5 | Wt 72.576 kg (160 lb) | BMI 26.63 kg/m2  Body mass index is 26.63 kg/(m^2).       Physical Exam:  Constitutional: no acute distress and well developed/well nourished  Eyes: lids/conjuctiva normal, anicteric and normal exam  Ears/Nose/Mouth/Throat: oropharynx pink and dry mucous membranes.  Cardiovascular: normal s1, s2, no murmurs, no pericardial friction rub and no gallops  Respiratory: clear to auscultation bilaterally, no wheezing and no rales  Abdomen:  Normoactive bowel sounds, nontender, nondistended. No rebound or guarding.  + palpable kidneys.   Back: no costo-vertebral tenderness (CVAT)  Musculoskeletal: normal gait.  Tense trapezius muscles  Lower Extremity: no peripheral edema.   Neurologic: alert, awake and  oriented times three (AAand 0 x3), normal light touch sensation, normal strength and no asterixis  Lymphatic: no cervical nodes palpated  Psychiatric: normal mood/affect, non-anxious and normal judgement and insight  Skin: no rash      Medical Decision Making:     Data Review:    UREA NITROGEN   Date Value Range Status   1/2/2013 57* 10 - 30 MG/DL Final       CREATININE   Date Value Range Status   1/2/2013 5.59* 0.50 - 1.30 MG/DL Final       ALBUMIN   Date Value Range Status   1/2/2013 4.4  3.5 - 4.9 G/DL Final       CALCIUM   Date Value Range Status   1/2/2013 9.2  8.5 - 10.5 MG/DL Final      _       PHOSPHORUS   Date Value Range Status   12/26/2012 4.1  2.4 - 4.7 MG/DL Final       No results found for this basename: URICACID       MAGNESIUM   Date Value Range Status   5/19/2011 2.1  1.5 - 2.5 MG/DL Final      NOTE: As of 7/16/09 the new reference range for Age 0-10 is 1.5 to 2.5 mg/dl       GLUCOSE   Date Value Range Status   1/2/2013 81  65 - 139 MG/DL Final      NON-FASTING 65-139 mg/dL      FASTING 65 - 99 mg/dL       No components found with this basename: VITAMIND12       INTACT PARATHYROID HORMONE   Date Value Range Status   12/26/2012 201* 16 - 87 PG/ML Final       WHITE BLOOD CELL   Date Value Range Status   12/26/2012 4.3* 4.5 - 11.0 x10 3/uL Final       HEMOGLOBIN   Date Value Range Status   12/26/2012 10.1* 11.7 - 15.0 G/DL Final       No components found with this basename: HCT       PLATELET   Date Value Range Status   12/26/2012 199  150 - 450 x10 3/uL Final       No components found with this basename: PROCREA       No components found with this basename: IMMUNOFIXSER       No components found with this basename: IMMUNOFIXURI       No results found for this basename: C3       No results found for this basename: C4       No results found for this basename: ANAQUANT       HEPATITIS BS AG   Date Value Range Status   5/19/2011 NON-REACTIVE  NON-REACTIVE Final       HEPATITIS C VIRUS AB   Date Value Range Status   5/19/2011 NON-REACTIVE  NON-REACTIVE Final       No components found with this basename: CRYOGLOB       TSH   Date Value Range Status   12/26/2012 1.10  0.34 - 5.60 uIU/Ml Final      Reference Ranges:            Age:            Female:     Male:      1-25 days       1.5-6.5    0.7-9.8      1-24 months     1.6-5.7    0.7-5.9      9-10 years      0.9-4.0    1.0-3.7      11-14 years     0.7-3.4    0.8-3.9      15-17 years     0.6-3.7    0.7-2.8      18-99 years     0.34-5.60  0.34-5.60       No results found for this basename: ANCA         Laboratory:   Cr was 4.54    Assessment/Plan:  1. CKD (chronic kidney disease) stage 4, GFR 15-29 ml/min  URIC ACID-BLD, URINALYSIS, ROUTINE, VITAMIN D 1, 25-DIHYDROXY, VITAMIN D, 25-HYDROXY, CK(CPK)-BLD, UREA-URINE RANDOM, CBC+PLT+DIFF, COMP METABOLIC PANEL(AKA CMP), ELECTROLYTES-URINE, MICROALBUMIN-URINE RANDOM, CREATININE-URINE RANDOM, MICROALB/CREAT,URINE (RAND), PARATHYROID HORMONE INTACT IRMA, PHOSPHORUS-BLOOD, PROTEIN/CREA.RATIO,URINE   2. Anemia  VITAMIN B12 and  FOLATE-SERUM, FERRITIN, IRON, IRON + TIBC   3. Hypertension  LIPID PANEL   4. Fatigue  TSH       51 F with PKD, CKD IV, HTN, tension headaches.     HTN:    Goal BP < or = 130/80 for maximal renal preservation.  Pt feels she is salt sensitive, but has not increased salt intake.      Headache may be from higher BP, or BP may be high due to tension headache.  D/w pt re: supportive measures (warm pack, shower water, bengay, massage) to help decrease tension in trapezius muscle. And f/u with BP.    In meantime, can take diovan 40 mg daily for now as it seems to help BP significantly.  D/w pt re:  Cr can increase with higher diovan, but that high BP itself can increase Cr.  Will need to determine f/u as we see how Bp does.  But will need repeat labs in about 2 weeks on increased diovan if she still requires higher dose diovan even with supportive methods to decrease tension headaches.     CKD:  From PKD.   Pt now on wait list for kidney tx.  She does not have a potential living donor.      Discussed with patient to avoid NSAIDS, Fleets phosphosoda, iv contrast for CT or angiograms if possible (and re: use of N-acetylcysteine for prophylaxis if contrast is needed), given CKD.    D/w pt re: timing of HD.  But with friend who wants to donate kidneyd/w pt re: preemptive Tx is best option.  To call Tx office to inquire instructions for friends workup    - Abdominal fullness:  GI doing EGD.  Gave lab copy to pt.  May be form enlarged kidneys. 2008 Us with 19 amnd 17 cm kidneysct 2011 with 17 cm.  Repeat u/s to eval kidney sizes.  Fullness may be from kidney size if GI w/u is neg.     Anemia:  Check fe studies, vitamin b12, folate.    F/u in 2 months.                                        History:     Chief Complaint: CKD PKD  HPI:  Charlene McDonald is a 52 y.o. female who returns for follow up of:  Stage III-IV CKD secondary to PKD.    Procardia  severe headaches; norvasc  didnt work after a few years;     Noticed very salt sensitive.     Drinks > 40 ounces of fluid per day.    Has abd fullnessseeing GI for EGD.  Increased fullness with meals.      Pt denies nausea, vomiting, MS change, fatigue, or bitter taste in mouth.    Patient has no dysuria, increased frequency, hematuria, or foamy urine.    Little less stress recently.  Son who is 27 years old has moved out of house as planned, living with girlfriend.      Has 2 weeks off for vacation.     Seeing Dr. Dudempuddi re: hernia and toe which may be fungal.    Friend is asking for Tx # because she is willing to donate.  But pt has not given the # yet.    Bp was very high one time because forgot to take labetolol on time, so now knows to take on time.  Review Of Systems:   Complete ROS performed. All systems negative except as detailed in HPI or below.    PMH: history reviewed and without changes.  Patient  has a past medical history of Polycystic kidney disease; HEMANGIOMA; and Gout (12/15/2011).    Family History: Reviewed and without changes.  Patient family history includes Dialysis in her mother and Polycystic Kidney Disease in her mother, others, and son.    Social History: Reviewed and without changes.   She  reports that she has never smoked. She does not have any smokeless tobacco history on file. She reports that she does not drink alcohol or use illicit drugs. Her sexual activity history not on file.    Medications:  Medications - Previous to this Encounter   Medication Sig Dispense Refill   ? labetalol 100 mg Oral tablet Take 4 tablets by mouth every 8 hours.  360 tablet  5   ? calcium carbonate 600 mg (1,500 mg) Oral tablet Take 1 tablet by mouth 3 times a day with meals.  90 tablet  5   ? valsartan (DIOVAN) 40 mg Oral tablet Take 1 tablet by mouth daily.  30 tablet  11   ? cholecalciferol (VITAMIN D3) 1,000 unit Oral capsule Take 1,000 Units by mouth daily.  30 capsule  5   ? sodium bicarbonate 650 mg Oral Tab Take 1 tablet by mouth 3 times a day.  90 tablet  5   ? Simethicone 80 mg Oral Chew Take 1 Tab by mouth every 8 hours as needed for Gas.   90  5   ? Multivitamin Oral Tab take 1 tablet by oral route once daily with food  30  5         Physical Exam:     Multi-System Exam:  BP 180/110 | Pulse 78 | Ht 5 5 | Wt 72.576 kg (160 lb) | BMI 26.63 kg/m2  Body mass index is 26.63 kg/(m^2).       Physical Exam:  Constitutional: no acute distress and well developed/well nourished  Eyes: lids/conjuctiva normal, anicteric and normal exam  Ears/Nose/Mouth/Throat: oropharynx pink and dry mucous membranes.  Cardiovascular: normal s1, s2, no murmurs, no pericardial friction rub and no gallops  Respiratory: clear to auscultation bilaterally, no wheezing and no rales  Abdomen:  Normoactive bowel sounds, nontender, nondistended. No rebound or guarding.  + palpable kidneys.   Back: no costo-vertebral tenderness (CVAT)  Musculoskeletal: normal gait.  Tense trapezius muscles  Lower Extremity: no peripheral edema.   Neurologic: alert, awake and  oriented times three (AAand 0 x3), normal light touch sensation, normal strength and no asterixis  Lymphatic: no cervical nodes palpated  Psychiatric: normal mood/affect, non-anxious and normal judgement and insight  Skin: no rash      Medical Decision Making:     Data Review:    UREA NITROGEN   Date Value Range Status   1/2/2013 57* 10 - 30 MG/DL Final       CREATININE   Date Value Range Status   1/2/2013 5.59* 0.50 - 1.30 MG/DL Final       ALBUMIN   Date Value Range Status   1/2/2013 4.4  3.5 - 4.9 G/DL Final       CALCIUM   Date Value Range Status   1/2/2013 9.2  8.5 - 10.5 MG/DL Final      _       PHOSPHORUS   Date Value Range Status   12/26/2012 4.1  2.4 - 4.7 MG/DL Final       No results found for this basename: URICACID       MAGNESIUM   Date Value Range Status   5/19/2011 2.1  1.5 - 2.5 MG/DL Final      NOTE: As of 7/16/09 the new reference range for Age 0-10 is 1.5 to 2.5 mg/dl       GLUCOSE   Date Value Range Status   1/2/2013 81  65 - 139 MG/DL Final      NON-FASTING 65-139 mg/dL      FASTING 65 - 99 mg/dL       No components found with this basename: VITAMIND12       INTACT PARATHYROID HORMONE   Date Value Range Status   12/26/2012 201* 16 - 87 PG/ML Final       WHITE BLOOD CELL   Date Value Range Status   12/26/2012 4.3* 4.5 - 11.0 x10 3/uL Final       HEMOGLOBIN   Date Value Range Status   12/26/2012 10.1* 11.7 - 15.0 G/DL Final       No components found with this basename: HCT       PLATELET   Date Value Range Status   12/26/2012 199  150 - 450 x10 3/uL Final       No components found with this basename: PROCREA       No components found with this basename: IMMUNOFIXSER       No components found with this basename: IMMUNOFIXURI       No results found for this basename: C3       No results found for this basename: C4       No results found for this basename: ANAQUANT       HEPATITIS BS AG   Date Value Range Status   5/19/2011 NON-REACTIVE  NON-REACTIVE Final       HEPATITIS C VIRUS AB   Date Value Range Status   5/19/2011 NON-REACTIVE  NON-REACTIVE Final       No components found with this basename: CRYOGLOB       TSH   Date Value Range Status   12/26/2012 1.10  0.34 - 5.60 uIU/Ml Final      Reference Ranges:            Age:            Female:     Male:      1-25 days       1.5-6.5    0.7-9.8      1-24 months     1.6-5.7    0.7-5.9      9-10 years      0.9-4.0    1.0-3.7      11-14 years     0.7-3.4    0.8-3.9      15-17 years     0.6-3.7    0.7-2.8      18-99 years     0.34-5.60  0.34-5.60       No results found for this basename: ANCA         Laboratory:   Cr was 4.54    Assessment/Plan:  1. CKD (chronic kidney disease) stage 4, GFR 15-29 ml/min  URIC ACID-BLD, URINALYSIS, ROUTINE, VITAMIN D 1, 25-DIHYDROXY, VITAMIN D, 25-HYDROXY, CK(CPK)-BLD, UREA-URINE RANDOM, CBC+PLT+DIFF, COMP METABOLIC PANEL(AKA CMP), ELECTROLYTES-URINE, MICROALBUMIN-URINE RANDOM, CREATININE-URINE RANDOM, MICROALB/CREAT,URINE (RAND), PARATHYROID HORMONE INTACT IRMA, PHOSPHORUS-BLOOD, PROTEIN/CREA.RATIO,URINE   2. Anemia  VITAMIN B12 and  FOLATE-SERUM, FERRITIN, IRON, IRON + TIBC   3. Hypertension  LIPID PANEL   4. Fatigue  TSH       52 F with PKD, CKD IV, HTN, tension headaches.     HTN:    Goal BP < or = 130/80 for maximal renal preservation.  Pt feels she is salt sensitive, but has not increased salt intake.      Bp well controlled today.    D/w pt re: taking labetolol every 12 hours to avoid rebound HTN, to keep a few pills in her bag always.     CKD:  From PKD.   Pt now on wait list for kidney tx.  She does not have a potential living donor but friend is interested in work uppt has not given her the # yet.  Friend asked againencouraged work up early to see if she is a match so if needed, can do preemptive tx.    Discussed with patient to avoid NSAIDS, Fleets phosphosoda, iv contrast for CT or angiograms if possible (and re: use of N-acetylcysteine for prophylaxis if contrast is needed), given CKD.     Fatigue:Improved.     Anemia:  Check fe studies, vitamin b12, folate.     Gout:  Check uric acid, esr, crp.        F/u in3 months.                                        History:     Chief Complaint: CKD PKD  HPI:  Charlene McDonald is a 52 y.o. female who returns for follow up of:  Stage III-IV CKD secondary to PKD.    Procardia  severe headaches; norvasc  didnt work after a few years;     Noticed very salt sensitive.     Drinks > 40 ounces of fluid per day.    Abd painLeft side closer to the front. Lasted all night at about 10/10. Took 2 tylenol and now is 3-4 out of 10 pain. No dysuria, hematuria, no fevers. Likely, burst cyst from PKD. No gravel, hematuria, or radiation to groin,     May 13th had bad headache, and BP was 210. Gave her reglan and it helped the headache. BP 190s. Was anxious.     Yesterday, BP 150/100.     Saw Dr. Duddenpuddi who told her that her EKG was irregularcardiologist said it may have been related to the way she was breathing.   Weight 182, BP was 160. Took extra labetolol. Eating well, and on weight watcherlost 8 pounds over 6 weeks. Avg 150-160 now. When taking diovan 40 mg (instead of the prescribed 20 mg), BP can decrease to 140s.    H/o diverticulitis 4 years agowas in ER and  given fluids.   Has had granola bar with nuts and seeds over 4 weeks.     Review Of Systems:   Complete ROS performed. All systems negative except as detailed in HPI or below.    PMH: history reviewed and without changes.  Patient  has a past medical history of Polycystic kidney disease; HEMANGIOMA; and Gout (12/15/2011).    Family History: Reviewed and without changes.  Patient family history includes Dialysis in her mother and Polycystic Kidney Disease in her mother, others, and son.    Social History: Reviewed and without changes.   She  reports that she has never smoked. She does not have any smokeless tobacco history on file. She reports that she does not drink alcohol or use illicit drugs. Her sexual activity history not on file.    Medications:  Medications - Previous to this Encounter   Medication Sig Dispense Refill   ? labetalol 100 mg Oral tablet Take 4 tablets by mouth every 8 hours.  360 tablet  5   ? calcium carbonate 600 mg (1,500 mg) Oral tablet Take 1 tablet by mouth 3 times a day with meals.  90 tablet  5   ? valsartan (DIOVAN) 40 mg Oral tablet Take 1 tablet by mouth daily.  30 tablet  11   ? cholecalciferol (VITAMIN D3) 1,000 unit Oral capsule Take 1,000 Units by mouth daily.  30 capsule  5   ? sodium bicarbonate 650 mg Oral Tab Take 1 tablet by mouth 3 times a day.  90 tablet  5   ? Simethicone 80 mg Oral Chew Take 1 Tab by mouth every 8 hours as needed for Gas.   90  5   ? Multivitamin Oral Tab take 1 tablet by oral route once daily with food  30  5         Physical Exam:     Multi-System Exam:  BP 180/110 | Pulse 78 | Ht 5 5 | Wt 72.576 kg (160 lb) | BMI 26.63 kg/m2  Body mass index is 26.63 kg/(m^2).       Physical Exam:  Constitutional: no acute distress and well developed/well nourished  Eyes: lids/conjuctiva normal, anicteric and normal exam  Ears/Nose/Mouth/Throat: oropharynx pink and dry mucous membranes.  Cardiovascular: normal s1, s2, no murmurs, no pericardial friction rub and no gallops  Respiratory: clear to auscultation bilaterally, no wheezing and no rales  Abdomen:  Normoactive bowel sounds, nontender, nondistended. No rebound or guarding.  + palpable kidneys.   Back: no costo-vertebral tenderness (CVAT)  Musculoskeletal: normal gait.  Tense trapezius muscles  Lower Extremity: no peripheral edema.   Neurologic: alert, awake and  oriented times three (AAand 0 x3), normal light touch sensation, normal strength and no asterixis  Lymphatic: no cervical nodes palpated  Psychiatric: normal mood/affect, non-anxious and normal judgement and insight  Skin: no rash      Medical Decision Making:     Data Review:    UREA NITROGEN   Date Value Range Status   1/2/2013 57* 10 - 30 MG/DL Final       CREATININE   Date Value Range Status   1/2/2013 5.59* 0.50 - 1.30 MG/DL Final       ALBUMIN   Date Value Range Status   1/2/2013 4.4  3.5 - 4.9 G/DL Final       CALCIUM   Date Value Range Status   1/2/2013 9.2  8.5 - 10.5 MG/DL Final      _       PHOSPHORUS   Date Value Range Status   12/26/2012 4.1  2.4 - 4.7 MG/DL Final       No results found for this basename: URICACID       MAGNESIUM   Date Value Range Status   5/19/2011 2.1  1.5 - 2.5 MG/DL Final      NOTE: As of 7/16/09 the new reference range for Age 0-10 is 1.5 to 2.5 mg/dl       GLUCOSE   Date Value Range Status   1/2/2013 81  65 - 139 MG/DL Final      NON-FASTING 65-139 mg/dL      FASTING 65 - 99 mg/dL       No components found with this basename: VITAMIND12       INTACT PARATHYROID HORMONE   Date Value Range Status   12/26/2012 201* 16 - 87 PG/ML Final       WHITE BLOOD CELL   Date Value Range Status   12/26/2012 4.3* 4.5 - 11.0 x10 3/uL Final       HEMOGLOBIN   Date Value Range Status   12/26/2012 10.1* 11.7 - 15.0 G/DL Final       No components found with this basename: HCT       PLATELET   Date Value Range Status   12/26/2012 199  150 - 450 x10 3/uL Final       No components found with this basename: PROCREA       No components found with this basename: IMMUNOFIXSER       No components found with this basename: IMMUNOFIXURI       No results found for this basename: C3       No results found for this basename: C4       No results found for this basename: ANAQUANT       HEPATITIS BS AG   Date Value Range Status   5/19/2011 NON-REACTIVE  NON-REACTIVE Final       HEPATITIS C VIRUS AB   Date Value Range Status   5/19/2011 NON-REACTIVE  NON-REACTIVE Final       No components found with this basename: CRYOGLOB       TSH   Date Value Range Status   12/26/2012 1.10  0.34 - 5.60 uIU/Ml Final      Reference Ranges:            Age:            Female:     Male:      1-25 days       1.5-6.5    0.7-9.8      1-24 months     1.6-5.7    0.7-5.9      9-10 years      0.9-4.0    1.0-3.7      11-14 years     0.7-3.4    0.8-3.9      15-17 years     0.6-3.7    0.7-2.8      18-99 years     0.34-5.60  0.34-5.60       No results found for this basename: ANCA         Laboratory:   Cr was 4.54    Assessment/Plan:  1. CKD (chronic kidney disease) stage 4, GFR 15-29 ml/min  URIC ACID-BLD, URINALYSIS, ROUTINE, VITAMIN D 1, 25-DIHYDROXY, VITAMIN D, 25-HYDROXY, CK(CPK)-BLD, UREA-URINE RANDOM, CBC+PLT+DIFF, COMP METABOLIC PANEL(AKA CMP), ELECTROLYTES-URINE, MICROALBUMIN-URINE RANDOM, CREATININE-URINE RANDOM, MICROALB/CREAT,URINE (RAND), PARATHYROID HORMONE INTACT IRMA, PHOSPHORUS-BLOOD, PROTEIN/CREA.RATIO,URINE   2. Anemia  VITAMIN B12 and  FOLATE-SERUM, FERRITIN, IRON, IRON + TIBC   3. Hypertension  LIPID PANEL   4. Fatigue  TSH       51 F with PKD, CKD IV, HTN, tension headaches.     HTN:    Goal BP < or = 130/80 for maximal renal preservation.  Pt feels she is salt sensitive, but has not increased salt intake.     Cont current BP meds.  Add lasix 20 mg bid or 40 mg daily on days BP is high as pt sometimes see BP 120-130 but increases when eats something salty.  BP great when she cooks but cant always .  Check weigtht daily.  If no change in BP in 3 days of lasix, call or email.  D/w pt to sue sparinglyonly when needed, as cr may increase with diuretics long term.       CKD:  From PKD.   Pt now on wait list for kidney tx.  Friend in California interested in donating.    Discussed with patient to avoid NSAIDS, Fleets phosphosoda, iv contrast for CT or angiograms if possible (and re: use of N-acetylcysteine for prophylaxis if contrast is needed), given CKD.    D/w pt re: timing of HD.  But with friend who wants to donate kidneyd/w pt re: preemptive Tx is best option.  To call Tx office to inquire instructions for friends workup    - Abdominal fullness:  GI doing EGD.  Gave lab copy to pt.  May be form enlarged kidneys. 2008 Us with 19 amnd 17 cm kidneysct 2011 with 17 cm.  Repeat u/s to eval kidney sizes.  Fullness may be from kidney size if GI w/u is neg.     Anemia:  Check fe studies, vitamin b12, folate.    F/u in 2 weeks.