DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: Pleural effusions and hypoxemia.
HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old male with a complicated past medical history, who has been on peritoneal dialysis since many years. The patient has a history of diabetes mellitus and coronary artery disease. He was recently admitted and was found to have a pelvic abscess secondary to sigmoid diverticular rupture. He was found to have an infected hemodialysis catheter. He underwent sigmoid resection and cholecystectomy, and after that, peritoneal dialysis could not be re-formed and he was switched over to hemodialysis and he has a right internal jugular dialysis catheter for this. The patient, however, during that time period states that he had at least 3 or perhaps 4 thoracenteses performed and we were asked to see him for the finding of pleural effusion, still persistent on chest x-ray, and also the need for increasing supplemental oxygen. The patient denies any shortness of breath at rest and only has minimal shortness of breath with exertion. He has engaged in physical therapy activities without difficulty.
CURRENT MEDICATIONS: Digoxin 0.125 mg daily, Zocor 20 mg daily, Protonix 40 mg daily, folic acid 5 mg, B complex 1 capsule daily, Colace 100 mg b.i.d., vitamin B12 1000 mcg every 30 days, nystatin 15 grams of powder topically, Panafil ointment daily, Accuzyme spray daily, Xenaderm ointment b.i.d., iron sulfate 325 mg daily, Epogen 10,000 units 3 times per week, ProAmatine 10 mg on dialysis days 1 tablet hour before and 1 tablet after the first hour of each hemodialysis. He is on Lotrimin 1% cream b.i.d. He is on Lantus insulin 12 units daily and regular insulin sliding scale, Cardizem 120 mg daily, Levaquin 250 mg daily, Coreg 12.5 mg b.i.d., Cozaar 50 mg b.i.d., Flagyl 250 mg t.i.d. He is also on Coumadin.
ALLERGIES: NO KNOWN DRUG ALLERGIES.
SOCIAL HISTORY: The patient is a former smoker having quit about 20 years ago, but he did smoke 1 to 2 packs per day for 8 years. There is also significant recent alcohol use.
FAMILY HISTORY: Noncontributory.
REVIEW OF SYSTEMS: He has no headache, fevers, chills or sore throat. He denies any neck pain or stiffness. He denies any chest pain. He has no purulent sputum production. He denies any abdominal pain, nausea or vomiting. He denies any diarrhea but did have some loose stools in the past. He has been getting his physical therapy and is ambulating with a walker. He does still have some lower extremity edema. He denies any specific muscle weakness. He has no hot or cold intolerance. He denies any known history of thromboembolic disease.
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 126/84, pulse 92, respirations 22, temperature is 96.8.
HEENT: Oropharynx clear. Nasopharynx clear. No sinus tenderness.
NECK: No increased jugular venous distention seen but there is a hemodialysis catheter in place, which limits the examination in the right internal jugular area. There is no obvious thyromegaly. Trachea is midline.
CARDIOVASCULAR: Regular rate and rhythm. S1 and S2 are normal. There is no murmur, gallop or rub.
LUNGS: Significant for decreased breath sounds at both bases approximately one-quater way up, but there is only mild egophony present, mostly at the right base.
CHEST: Expansion is symmetric. No accessory muscle use.
ABDOMEN: Soft and nontender. No palpable organomegaly, no masses. Bowel sounds present.
EXTREMITIES: Difficult to palpate but there does appear to be significant 1 to 2+ edema present in both lower extremities palpated through the patient’s devices on his lower extremities. Unable to palpate distal pulses in the lower extremities. Radial pulses are 2+.
NEUROLOGIC: The patient is alert and oriented x3. Motor examination was not able to be done completely. The patient’s face appears symmetric and he does move all extremities well.
DIAGNOSTIC/LABORATORY DATA: Chest x-ray was personally reviewed and shows bilateral pleural effusions and increased pulmonary and vascular congestion. Hemodialysis catheter is in place. CT of the abdomen shows cuts at the lower lung fields showing bilateral pleural effusions and associated atelectases.
INR from yesterday is 2.34 with a prothrombin time of 23.2. CBC: Hemoglobin 13.6, hematocrit 41.2, white cell count 11.2, and platelets 164,000. C-reactive protein from yesterday is 4.94, elevated. Chemistries; sodium 136, potassium 4.6, chloride 102, bicarbonate 30, BUN 32, creatinine 3.6, glucose 142. Sedimentation rate was mildly elevated at 24.
ASSESSMENT:
1. Bilateral pleural effusions, likely secondary to congestive heart failure.
2. Respiratory insufficiency.
3. Hypoxemia.
4. Atelectasis.
5. End-stage renal disease.
PLAN: We will recheck chest x-ray and suggest as much as possible fluid removal with hemodialysis. If the patient needs thoracentesis, we will send the patient across the street for ultrasound guidance. We will add nebulizers with Xopenex and Atrovent and continue oxygen therapy. Because of the patient’s elevated INR, if a decision to do a thoracentesis is done, the patient’s Coumadin will have to be held and INR will have to be followed to less than 1.5 range.
