Patient: [Patient Name] MRN: [Medical Record Number] Date: [Date of Encounter]
I. Transplant Information
Transplant Date:
Donor Type (Living/Deceased):
Immunosuppression Regimen: (Medications, dosages)
Last Rejection Episode (if applicable): Date, type (acute/chronic)
II. Subjective
Symptoms:
Fever, chills
Urinary output (frequency, amount, color)
Flank pain
Nausea, vomiting
Fatigue
Wound healing concerns
III. Objective
Vital Signs: (BP, HR, RR, Temp)
Physical Exam:
General: Appearance of illness, edema
Abdominal: Wound site appearance, tenderness, distention
Skin: Rash (presence, location)
Laboratory:
Serum creatinine and estimated glomerular filtration rate (eGFR)
Electrolytes (potassium, sodium)
Complete blood count (CBC)
Blood urea nitrogen (BUN)
Urinalysis (protein, blood)
Tacrolimus/Cyclosporine levels (if applicable)
CMV (cytomegalovirus) testing (if applicable)
IV. Imaging (if performed)
Doppler ultrasound of transplanted kidney: Assess blood flow, signs of rejection.
V. Assessment
Graft function: (Normal, improving, stable, declining) based on creatinine and eGFR
Immunosuppression status: Therapeutic levels, potential for medication adjustments
Wound healing: Progress of surgical site
VI. Plan
Medications: Adjust immunosuppressant medications as needed based on lab results and clinical status.
Laboratory monitoring: Repeat labs (creatinine, electrolytes, immunosuppressant levels) at designated intervals.
Imaging follow-up: Consider repeat Doppler ultrasound if graft function declines or rejection is suspected.
Biopsy (if indicated): If suspicion of acute rejection is high, a kidney biopsy may be necessary for definitive diagnosis.
Infection prophylaxis/treatment: Continue or adjust medications to prevent or treat infections like CMV.
Referral: Consider referral to an infectious disease specialist for complex infection management.
Education: Educate the patient on signs and symptoms of rejection, importance of medication adherence, and healthy lifestyle habits post-transplant.
Follow-up: Schedule next appointment in [interval] based on graft function and clinical stability.