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SOAP note
Anya Harmon
Reports recurrent bilateral ankle swelling by evening, home BP readings ~148/92, and foamy urine over the past week.
BP 146/90; mild bilateral pedal edema. Prior BMP showed eGFR 38.
CKD stage 3b with hypertension; worsening proteinuria.
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Anya Harmon
Reports recurrent bilateral ankle swelling by evening, home BP readings ~148/92, and foamy urine over the past week.
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Anya Harmon F/U May 12
Any recent med changes?
No.
Lisinopril 10 mg daily — unchanged
No new prescriptions or OTC meds
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Dear Anya,
It was good to see you today for your kidney follow-up. We reviewed your recent labs — your eGFR is 38 mL/min with worsening proteinuria.
Please continue lisinopril 10 mg daily. Avoid NSAIDs (ibuprofen, naproxen). Follow a low-sodium diet (<2,000 mg/day) and limit fluids to 1.5 L per day as discussed.
Repeat BMP and urine albumin in 3 months. A renal dietitian referral has been sent. Call the office if you notice worsening leg swelling, foamy urine, decreased urine output, or blood pressure readings above 150/90.
Sincerely, Dr. Patel
Billing Suggestions
N18.32 — Chronic kidney disease, stage 3b
I12.9 — Hypertensive chronic kidney disease with stage 1 through stage 4 CKD, or unspecified CKD
R80.9 — Proteinuria, unspecified
99214 — Office visit, established patient, moderate complexity
Justification
Extended HPI for CKD monitoring and symptom review; moderate MDM with BMP/eGFR interpretation, ACE inhibitor management, and renal dietitian referral coordination.
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