Patient: [Patient Name]
Date: [Date of Encounter]
I. Reason for Encounter:
Evaluation for suspected contrast-induced nephropathy (CIN) following exposure to intravenous contrast
II. History of Present Illness:
Date and type of intravenous contrast administered
Reason for contrast administration (imaging study)
Onset and characteristics of new symptoms (decreased urine output, oliguria, anuria, rise in serum creatinine)
III. Past Medical History:
Underlying kidney disease (chronic kidney disease – CKD, chronic kidney disease stage, history of acute kidney injury – AKI)
Diabetes mellitus
Hypertension
Previous episodes of CIN
IV. Medications:
Current medications, including nephrotoxic medications (e.g., diuretics, angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs))
V. Vital Signs:
Blood pressure (BP)
Heart rate (HR)
Respiratory rate (RR)
Temperature (Temp)
VI. Physical Exam:
General appearance (evidence of dehydration)
Signs of volume overload (pulmonary edema) – if severe CIN
VII. Laboratory Studies:
Serum creatinine (baseline and current)
Urine output
Urinalysis (presence of protein, blood)
Electrolytes
VIII. Assessment:
Suspected CIN based on clinical presentation (new decrease in kidney function) following contrast exposure
Severity of CIN (based on rise in creatinine and urine output changes)
Risk factors for CIN (pre-existing kidney disease, diabetes, hypertension, contrast volume)
IX. Plan:
Treatment depends on severity of CIN:
Mild CIN:
Intravenous fluids for hydration
Monitor kidney function with serial creatinine measurements
Consider holding nephrotoxic medications (if applicable)
Moderate or severe CIN:
Aggressive intravenous hydration
Diuretics (if indicated)
Nephrology consultation may be necessary
Avoidance of repeat contrast exposure if possible
Consider alternative imaging modalities (ultrasound, MRI) that do not require contrast in the future
X. Prognosis:
Discuss the potential course of CIN, including the likelihood of recovery of kidney function.
Emphasize the importance of preventing future episodes by avoiding unnecessary contrast exposure and optimizing medical management of underlying conditions.
XI. Notes:
Include any additional observations or concerns, such as patient’s understanding of CIN, adherence to hydration recommendations, and need for close follow-up.
XII. Resources:
Consider providing patient education materials on contrast-induced nephropathy from reputable sources (e.g., American College of Radiology, National Kidney Foundation).