The last time I saw patients at the nephrology out patient clinic under the guidance of a nephrologist I thought to myself “I should write notes about this for future reference”. And then I thought “but I don’t think its THAT useful” and I didn’t, and I had forgot much of what I had learnt before.
True, in medicine, if you don’t use it, you lose it.
So today I am making some short notes. Yes, I think this would be useful for anyone who has never worked in a nephrology unit before. But I have learnt that there are many other patients such as those who undergo long term CAPD and also the renal transplant patients whose management are slightly different and will be likely to encounter other issues.
In my first ever job as a senior house officer or medical officer in general medicine many, many years ago, in Mullingar General Hospital in County West Meath, Ireland, which was about an hours drive away from our then Dublin home, or 55 miles one way, I learnt a few things about medical out patient management.
We (me and another Irish first time S.H.O. named Karina, whom I would love to get in touch with but have not found on FB), were thought by our then registrar (cardiologist) to have a simple layout as below when seeing patients in the OPD:
- List down on previous diagnosis example diabetes, hypertension, stroke, ischaemic heart disease etc
- List down all current medications including dose
- State current condition/status/any new complaints/problems/outstanding issues example patient is well, no complaints, or discharged from ward x 3 weeks ago for elective lap-chole etc
- Do a brief physical examination and state findings
- In the beginning, we were required to discuss all cases with the registrar/consultant, so can write down discussed with Dr O’Brien etc
- Write down the plan, whether to perform new tests, change dose of medication and when patient is to return for the next check.
For long term haemodialysis patients, it is SLIGHTLY different.
- List down how long patient has been undergoing HD and via what access example 2 years via left fistula
- Write down the Qb or blood flow during HD, the URR and Kt/V values (these reflect adequacy of dialysis). URR should be more than 65% and Kt/V should be 1.2. (For most patients, they do receive adequate dialysis – speaking based on limited experience).
- List down all relevant diagnosis, which essentially means cause of ESRD if known, and any other cardiovascular risk factors like diabetes, hypertension, etc, of course these can overlap. A lot of patients have diabetes and hypertension, some have other CKD like APCKD, glomerulonephritis, in others, the cause is unknown.
- Note down current patient status, whether the patient is well or otherwise and the nature of the problem
- The next thing to do is to look at the blood test results.I am quite impressed with the patient notes because I think it is kept very well organised by the staff and information is easy to retrieve making the clinic session efficient. There is one whole page of figures ranging from urea pre and post dialysis, electrolytes, liver function test, calcium, phosphate, magnesium, intact PTH, haemoglobin and other blood parameters.
- At the very top of the page, there is usually written the patients blood pressure, pulse and weight that day. Also make note of the dry weight. If there is a chest x-ray, subjectively measure the cardio-thoracic ratio. This assessment of fluid status takes into consideration patients symptoms of shortness of breath, leg swelling, compliance to water restriction and inter-dialytic weight gain plus ultrafiltration (how much fluid was removed at each HD session).
- Review the current medications. Most would be oral medication except for erythropoietin (eprex is a common brand used), iron (mostly given IV example venofer but some patients do take ferrous fumarate), and vitamin D or alfa calcidol.
- All patients will be taking calcium carbonate as a resin to bind phosphate. Many take 3-4 tablets (500mg) three times a day, they are always reminded to chew it with rice. If the calcium levels (adjusted according to albumin) are low, or the phosphate is increased, advise patient to reduce food containing phosphate. Many patients though not all are not complaint, taking medication as and when they please, some complaint of lack of appetite, so they dont eat rice and hence do not take the calcium carbonate tablets. Ask the patient if they have any bone pains and educate them on the importance of preventing bone disease.
- Many patients have low Hb although not all. We dont assume that all anaemia is due to erythropoietin defficiency. Have to assess and make sure patient is not bleeding and iron levels are adequate. Transferrin saturation is a good indicator of adequate iron levels (more than 20%). If not adequate, patient may need iron IV or oral, if iron is adequate then can gradually increase the erythropoietin levels.
- Always advise those that smoke to stop smoking. They are already at increased risk form heart disease due to the kidney failure.