DATE OF RENAL CONSULT: MM/DD/YYYY
CONSULTING PHYSICIAN: John Doe, MD
REQUESTING PHYSICIAN: Jane Doe, MD
REASON FOR CONSULTATION: To evaluate the patient for acute renal failure.
SOURCE AND RELIABILITY: History obtained from medical records. Unable to obtain history from the patient because he is intubated.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old male with history of coronary artery disease, hypertension, history of bypass surgery, chronic anemia with 3-month history of shortness of breath with exertion. The patient denied associated chest pain. He had worsening symptoms over the past week prior to admission. He underwent an outpatient dobutamine stress test. This was negative for reversible ischemia. Left ventricular ejection fraction was 35% and heart rhythm was irregular. The patient was admitted for further cardiac workup of atrial fibrillation. He was in congestive heart failure and required IV diuretics. BUN and creatinine on admission was 8.5 and 0.8 and H and H was 8.8 and 27.4.
The patient underwent EGD and colonoscopy for evaluation of chronic anemia. EGD showed multiple antral erosions with chronic gastritis and colonoscopy revealed an ascending colon mass, 75% occlusion. Pathology is positive for moderately differentiated adenocarcinoma. The patient also had problems with bradyarrhythmias, which required pacemaker placement. He developed a brief episode of acute encephalopathy, which resolved on its own. EEG did not show any seizures. The patient was being optimized for right colectomy. He is having problems with elevated LFTs and coagulopathy, which is being corrected with FFP. Yesterday, the patient developed acute onset of shortness of breath requiring intubation. He became hypotensive post medications.
The patient developed acute renal failure with baseline creatinine of 0.8, yesterday 1.8. Today, creatinine is 2.8. Therefore, renal consult has been obtained. The patient did receive boluses of IV fluids, and despite that, urine output has been marginal. Lasix drip was started overnight with no improvement today. The patient is anuric. He is currently on norepinephrine drip. The patient does not have any evidence of prior kidney disease. CT scan of the abdomen with IV contrast was performed and this revealed nonobstructive, right-sided renal stones.
PAST MEDICAL HISTORY: Hypertension; coronary artery disease status post CABG, negative recent dobutamine stress test for ischemia; atrial fibrillation/sick sinus syndrome status post dual chamber pacemaker; hyperlipidemia; chronic anemia; right colon moderately differentiated adenocarcinoma diagnosed during this hospitalization; chronic gastritis, EGD performed during this hospitalization; right renal stones diagnosed this hospitalization by CT scan; borderline diabetes, which has been diet controlled; glaucoma of the right eye; status post appendectomy.
MEDICATIONS PRIOR TO ADMISSION: Lopid 600 mg p.o. b.i.d.; Crestor 10 mg p.o. daily; diltiazem 120 mg slow release one daily; enalapril 10 mg p.o. b.i.d.; aspirin 325 mg daily; Lumigan 0.03% ophthalmic drops both eyes at bedtime; Timolol 1 drop, right eye, q.a.m.; Alphagan 1 drop, right eye, b.i.d.; Aleve p.r.n. pain. and Tylenol p.r.n. pain.
CURRENT MEDICATIONS: Norepinephrine drip at 26.6 mcg per minute; propofol drip; fentanyl drip; Lasix drip at 40 mg per hour; insulin drip; Combivent puff MDI; amiodarone 400 mg p.o. b.i.d.; Lumigan 1 drop, both eyes, at bedtime; Alphagan 0.15% ophthalmic drop b.i.d., right eye; Celebrex 200 mg p.o. daily; TPN at 70 mL per hour; gemfibrozil 600 mg p.o. b.i.d.; Prevacid 30 mg NG b.i.d.; lisinopril 10 mg p.o. daily, last dose given yesterday; Zosyn 2.25 grams IV q.6 h., started yesterday; Diprivan drip; Crestor 10 mg p.o. daily; Timolol 0.5% ophthalmic solution, right eye, one drop daily and Vancomycin 1 gram IV q.24 h.
ALLERGIES: NO KNOWN DRUG ALLERGIES.
FAMILY HISTORY: Mother is alive at age 89. Father deceased at age 76. Four siblings; one brother passed away from some type of cancer, another sister passed away from heart disease. The patient has one son and one daughter, both are in generally good health. There is no family history of chronic kidney disease.
SOCIAL HISTORY: The patient is currently married. The patient is a prior smoker. Drinks socially.
REVIEW OF SYSTEMS: Unable to obtain review of systems from the patient because he is intubated.
PHYSICAL EXAMINATION:
VITAL SIGNS: Temperature 98.8, temperature up to 100.8 yesterday; pulse 102; respiratory rate 18; blood pressure 114/52; saturating at 97%. The patient is intubated. Weight on admission 68 kilos. Current weight is 82 kilos. I’s and O’s; 3735 in, 1490 out. Urine output is 0. Swan-Ganz catheter reading; CVP 14 to 17, wedge 18. Cardiac index 2 to 3, up to 4.2.
GENERAL APPEARANCE: The patient is a well-developed male, intubated.
HEENT: Normocephalic, atraumatic. Pupils are reactive. Nose clear. Mouth; ET tube and NG tube present.
NECK: Supple. No obvious carotid bruits. Jugular venous distention is present.
BACK: Unable to examine. The patient is intubated.
LUNGS: Anterior is clear.
HEART: Irregularly irregular, healed median sternotomy scar.
ABDOMEN: Distended with decreased bowel sounds, right lower quadrant appendectomy scar.
EXTREMITIES: 2+ edema with some scrotal edema.
GENITOURINARY: Foley catheter is in place.
JOINTS: No synovitis.
MUSCULOSKELETAL: Normal tone.
SKIN: No systemic rash. Peripheral pulses are intact.
NEUROLOGIC: The patient is intubated and sedated.
LABORATORY DATA AND DIAGNOSTIC DATA: Sodium 133, potassium 3.9, chloride 104, bicarbonate 22, BUN 74, creatinine 2.8, creatinine yesterday 1.8. On admission, BUN 8, creatinine 0.8. Phosphorus 4.4, magnesium 2.3, calcium 8.3, albumin 2.9, total CK 105, BNP 445. Lactic acid 2.5. Total bilirubin 2.2, direct bilirubin 0.8, alkaline phosphatase normal at 77. LFT elevated at 346, peaked at 966, AST 169 which peaked at 1198. Hemoglobin 10.8, hematocrit 32.6, white blood cell count 33.4, yesterday 40; neutrophils 89, bands 8, lymphocyte 1, monocytes 2, platelet count 52. INR 1.8, PT 19.8. TSH is normal at 1.8. Blood gas; pH 7.34, PCO2 35, PO2 112, bicarbonate 19, saturating at 98%. Urinalysis; pH 5.6, protein 100, large blood and large leukocyte esterase, positive nitrite, greater than 100 rbc’s, white blood cells 510 and a few bacteria. Urine culture showed greater than 100,000 of E. coli; it is sensitive to Zosyn. Blood cultures later on showed no growth to date. TIBC is 514, total iron is 32, ferritin is 5, CEA is 18.2.
Chest x-ray performed today and reviewed by me showed cardiomegaly with right upper chest wall pacemaker. Pulmonary edema is present with increasing right pleural effusion. Chest x-ray is worse compared to the prior x-ray. Also, right lower infiltrate present. Echocardiogram performed during his hospitalization showed ejection fraction of 40% to 45% with mid inferoseptal, apical septal and apical anterior wall hypokinesis. Right atrial and left atrial enlargement mild to moderate. Mild to moderate mitral regurgitation and tricuspid regurgitation. Moderate pulmonary hypertension. EKG reviewed by me showed PR interval 166 milliseconds, QTc 384 milliseconds. Q-waves in inferior leads, poor R-wave progression. Inferolateral T-wave inversions. CT scan of the abdomen and pelvis with IV contrast showed fatty infiltration of liver and no evidence of metastatic disease. Right renal stones, 5 mm, nonobstructing calculus in upper pole of right kidney and second calculus in lower pole. Cardiomegaly and tiny right pleural effusion.
IMPRESSION:
1. Acute renal failure. This is due to prerenal sepsis, congestive heart failure in a patient newly diagnosed with right colon carcinoma. Renal function is worsening despite challenges with IV fluids. The patient remains anuric despite Lasix drip. The patient will need continuous hemodialysis. No evidence of obstruction. The patient is currently on broad spectrum antibiotics. The patient did receive IV contrast during this hospitalization; however, his creatinine remained stable. It is unlikely to be the primary cause of his current acute renal failure.
2. Renal stone which is nonobstructive. This can be worked up as an outpatient when the patient stabilizes.
3. Right colon carcinoma. The patient needs a colectomy once he is medically stable.
4. Coronary artery disease with cardiomyopathy and new onset of atrial fibrillation.
5. Elevated LFTs. This may be due to congestive heart failure and this is improving. We will rule out hepatitis.
RECOMMENDATIONS:
1. We will initiate continuous hemodialysis today and remove fluid. Consent has been obtained over the phone from the patient’s durable power of attorney, who is his son.
2. We will check hepatitis B and C serologies.
3. Continue IV antibiotics.
4. Discontinue Celebrex.
We will follow along closely with you. Thank you for this referral.
