DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
CONSULTING PHYSICIAN: Jane Doe, MD
REASON FOR CONSULTATION: Assistance with acute renal failure superimposed on chronic kidney disease.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old female with a history of CKD stage III secondary to membranoproliferative glomerulonephritis. This was accompanied by significant nephrotic syndrome and microscopic hematuria. Urine protein prior was 5.9 grams, and at the time of her renal biopsy, it was as high as 18 grams. Serologies were done and these were all negative. In particular, her ANA was negative, ANCA negative, hepatitis A, B, and C negative, HIV negative, ASO less than 200. C3, C4, and CH50 were all negative. She had generalized edema secondary to her nephrotic syndrome and was treated with diuretics. She had hyperlipidemia. Creatinine was 1.7 last April. She had two hospitalizations; the first in September-October when her glomerulonephritis was diagnosed and then again in December with recurrence of her edema. She was treated with dipyridamole, fish oil capsules, and prednisone. She was initially evaluated by me last April. At that time, BUN was 20, creatinine 2.2, hemoglobin 9.4, albumin 1.2, potassium 3.3. She required diuretics for treatment of her edema. Blood pressures were stable at 120/80. Again, repeat serologies were performed. C3-C4 levels normal, ANA negative, CH50 normal, hepatitis B and C antibody negative. Creatinine was 1.8 in December. Albumin 1.5, hemoglobin 9.8, cholesterol 459, and triglycerides 155. Subsequently, she was placed on Crestor, PhosLo and lisinopril to reduce the urine protein. Urine protein-to-creatinine ratio could not be determined because of her extremely high urine protein. Urine sediment examined in the office showed evidence of significant microscopic hematuria with dysmorphic red cells. When last seen in the office, her labs on recheck showed creatinine of 1.8, BUN 26. Electrolytes were normal. Albumin 1.4, glucose 79, hemoglobin 9.9, TSH high at 10, ferritin 202, percent saturation of iron 34, PTH level 42, cholesterol 226, triglycerides 165, LDL 162, phosphorous 6.4, free T4 normal at 0.9. When seen in December, she admitted that she had stopped all of her medications one week ago on her own. She had been counseled about the importance of taking medications. At that time, Lasix, Theo-Dur and PhosLo were prescribed. The patient was admitted on this occasion with epigastric abdominal pain. On exam in the emergency room, blood pressure was 118/86, pulse 68, she was afebrile. Chest was clear. Heart sounds regular. Abdomen: There was some mild tenderness. No rebound. Bowel sounds were normal. There was no peripheral edema.
A CAT scan of the abdomen and pelvis was done. This showed a 1.5 mm nonobstructing calculus at the lower pole of the right kidney. No obstruction. There were post cholecystectomy changes in the right upper quadrant. White count was 7500, hemoglobin 9.8, hematocrit 28.4, BUN 34, creatinine higher at 3.3, potassium 4.4, CO2 of 24, calcium 8.2, glucose 105. The albumin was low at 1.8. Liver function tests normal. Lipase normal at 27. Urinalysis: pH of 6.2, protein 300 mg/dL, large blood, negative leukocyte esterase, positive nitrite. Microscopic exam showed many epithelial cells, 2 to 5 white cells, 20 to 50 red cells, and many bacteria. Urine culture was sent and to date is growing greater than 100,000 multiple non-predominating organisms. She was placed on an IV of normal saline at 75 mL per hour, started on IV ceftriaxone. Blood cultures are negative to date. Renal ultrasound was also done; this shows normal size kidneys with diffusely increased echogenic parenchyma suggestive of chronic medical renal disease. No obstruction. Her blood pressures have been normal in the hospital. Intake and output yesterday was 1800 in and 1500 out. Her abdominal pain has resolved on its own. BUN today is 32 and creatinine improved at 2.9. CO2 level 21, calcium 7.6, phosphorous 5.4, magnesium 2.2. Her hemoglobin is down to 8.6, hematocrit 24.3, MCV 87, white count 7700, TSH 7.03, free T4 normal at 0.6.
Today, she was switched from IV ceftriaxone to oral Cipro, is eating well, tolerating a regular diet, and in general feels much better. She denies any dysuria. No gross hematuria. She has not had any recent leg swelling. She states that she was on no medications prior to admission. She states that she has not eaten any unusual foods.
PAST MEDICAL HISTORY: History of prior cholecystectomy, hyperlipidemia secondary to nephrotic syndrome, chronic membranoproliferative glomerulonephritis as described above.
ALLERGIES: NO KNOWN DRUG ALLERGIES.
MEDICATIONS: None prior to admission. Currently, in hospital, she is on ciprofloxacin 250 mg p.o. daily, started today; Colace 100 mg b.i.d.; normal saline IV at 75 mL per hour.
SOCIAL HISTORY: The patient lives with her family. She does not smoke or drink alcohol.
FAMILY HISTORY: Positive for diabetes, hypertension, and kidney disease.
REVIEW OF SYSTEMS: Negative apart from the above.
VITAL SIGNS: Blood pressure 108/68, heart rate 66, respiratory rate 20, and temperature 98.5 degrees.
GENERAL: Alert, comfortable, in no acute distress.
HEENT: Conjunctivae pale. Sclerae anicteric.
CHEST: Clear. Good air entry.
BACK: No flank tenderness. No presacral edema.
HEART: PMI normal. Heart sounds regular. Soft grade 2/6 systolic ejection murmur at left lower sternal border. No rub.
ABDOMEN: Soft and nontender. Bowel sounds normal. Liver and spleen not palpable. No renal area bruits.
EXTREMITIES: Lower extremities, trace edema pretibially. Peripheral pulses strong bilaterally. No rash. No arthritis.
1. Acute kidney injury, may be due to urinary tract infection and abdominal pain with subsequent hypovolemia. Her renal function has improved with IV hydration.
2. Chronic kidney disease, stage III. Baseline creatinine 1.7 to 2 secondary to chronic membranoproliferative glomerulonephritis with nephrotic syndrome and associated hyperlipidemia.
4. Mild metabolic acidosis.
5. Hyperphosphatemia secondary to renal failure.
6. Previous vitamin D deficiency.
1. Agree with placing the patient on oral antibiotics. Since she is eating well, by tomorrow, IV fluid should be able to be discontinued.
2. Recommend low-cholesterol diet and low-sodium renal diet.
3. Once her renal function has improved, we will restart lisinopril to reduce her significant proteinuria.
4. Regarding her anemia, previous iron studies were normal. This could be repeated as an outpatient. Her chronic anemia is most likely secondary to her chronic kidney disease.
5. She has mild hyperphosphatemia. Continue renal diet. Recommend starting PhosLo one t.i.d. after meals as an outpatient. We will recheck her PTH level and her vitamin D level.
Thank you for asking me to see this patient in consult. I will follow her with you regarding her renal disease.
DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
CONSULTING PHYSICIAN: Jane Doe, MD
REASON FOR CONSULTATION: Assistance with renal failure. The patient is on chronic hemodialysis.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old male with a history of end-stage renal disease secondary to diabetic nephropathy. He is on chronic hemodialysis three times a week, Monday, Wednesday and Friday. He also has a history of hypertension, diabetes mellitus type 2, obesity, chronic osteomyelitis of the left leg, and hyperlipidemia. He has been on hemodialysis for approximately three months. He initially had a left wrist Cimino fistula placed. This failed to mature; therefore, he has been dialyzing via a right internal jugular vein PermCath. He received a new left wrist AV fistula approximately two months ago, which is maturing nicely. The patient felt well until Thursday, when he developed fever and chills while on his hemodialysis. He, therefore, presented to the emergency room, where he also had low back pain, abdominal pain, nausea and vomited thrice. Blood cultures were done. Abdominal CT scan showed evidence of edema but no evidence of infection. White count was elevated at 19,000 with 88 segs, no bands, hemoglobin 11, and platelet count 259,000. Chest x-ray showed no acute infiltrates. There was minimal left basilar atelectasis. He was started on vancomycin and Zosyn. He feels better. White count today is down to 11,500 and hemoglobin is 9.3 today. His calcium yesterday was 6.8, last albumin 1.8, and potassium 4.1.
PAST MEDICAL HISTORY:
1. End-stage renal disease secondary to diabetic nephropathy, on chronic hemodialysis. He dialyzes on Monday, Wednesday, and Friday. His usual dialysis treatment is potassium bath of 3.0, dry weight is 145 kg, time is 3 hours and 30 minutes via a right internal jugular vein PermCath.
4. Diabetes mellitus type 2.
5. Chronic osteomyelitis of the left leg requiring multiple surgeries in the past, status post external fixation.
7. History of necrotizing fasciitis, left lower leg.
8. History of periorbital cellulitis bilaterally.
9. History of cataract surgery of the left eye.
MEDICATIONS PRIOR TO ADMISSION: Metoprolol, sodium bicarbonate, Novolin insulin, atorvastatin, doxycycline, Cipro, and Cozaar.
CURRENT MEDICATIONS: Lipitor 20 mg daily; sodium bicarbonate 650 mg t.i.d.; Zosyn 2.25 grams IV every 8 hours; insulin 70/30, 20 units in the morning and 35 units in the evening; vancomycin 750 mg with each hemodialysis.
ALLERGIES: NO KNOWN ALLERGIES.
SOCIAL HISTORY: Does not smoke or drink alcohol.
FAMILY HISTORY: Positive for diabetes, renal disease, and hypertension.
GENERAL: The patient is alert and comfortable, in no acute distress.
VITAL SIGNS: Blood pressure 144/80, pulse 82, temperature 98.4 degrees and respiratory rate 20.
CHEST: Clear. Right IJ PermCath with a clean dressing. He has a left wrist AV fistula, which is maturing nicely with a good bruit.
HEART: Heart sounds regular, soft systolic murmur at left lower sternal border.
ABDOMEN: Soft, nontender. Bowel sounds normal.
EXTREMITIES: Lower extremities show that the right leg has a trace of pretibial edema and the left leg is in an orthopedic device.
1. Fever, leukocytosis, improving on antibiotics, possibly secondary to PermCath.
2. End-stage renal disease secondary to diabetic nephropathy, on chronic dialysis.
4. Hypocalcemia, history of hyperphosphatemia. The patient has been on PhosLo in the past.
5. Metabolic acidosis, on sodium bicarbonate as an outpatient.
6. Anemia secondary to renal failure.
1. We will arrange for hemodialysis tomorrow.
2. Epogen 10,000 units three times a week on dialysis.
3. Continue renal diet.
4. PhosLo one t.i.d. with meals.
5. Continue sodium bicarbonate.
6. Check chemistry, CBC tomorrow.
Thank you for asking me to see the patient. I will follow him with regards to his renal disease.