DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: Acute renal failure.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old with history of hepatitis C and cirrhosis of the liver. He was sent to the emergency room from the nursing home with a history of painful lower extremities, decreased urine output, and petechial lesions over his extremities. The patient himself is a very poor historian. He also appears to be disoriented to time, and therefore, reliable history could not be obtained from the patient. The nursing home note also suggests that the patient had been confused. Also noted was increased severity of his skin lesions, and the patient had not voided for about 8 hours prior to his transfer to the emergency room.
PAST MEDICAL HISTORY: Significant for cirrhosis of the liver, history of hepatitis C, history of type 2 diabetes, coronary artery disease, hypertension, spinal stenosis, herniated disk, history of osteoarthritis, and benign prostatic hyperplasia.
PAST SURGICAL HISTORY: Includes cholecystectomy, appendectomy, and hernia repair.
MEDICATIONS: In the nursing home included Aldactone 25 mg b.i.d., sliding scale insulin, folic acid, Lortab, Glucotrol XL 10 mg daily, Ativan 1 mg q 6 hours p.r.n., multivitamin, vitamin C, Benadryl, Protonix, Inderal 10 mg daily, and Lasix 20 mg b.i.d. The patient also was on ProMod milkshake.
It also appears that he was admitted just recently, earlier this month. He was discharged with a PICC line for unclear reasons. It appears that the PICC line was removed two weeks ago. He also had a large-volume paracentesis last month.
SOCIAL HISTORY: Unobtainable from the patient. Previous H and P suggests that he has no history of tobacco but is a recovering alcoholic, who has been sober for the past five years.
FAMILY HISTORY: Significant for coronary artery disease.
PHYSICAL EXAMINATION:
GENERAL: The patient is lethargic and confused. He is oriented to place and person but does not remember sequence of events that made him get hospitalized.
VITAL SIGNS: His blood pressure is ranging between 116 and 128 systolic, diastolic between 70 and 84. Pulse is in the 80s. Intake/output recorded as 500 mL in and 120 mL out.
HEENT: Pupils are round and reactive to light.
NECK: Supple. No jugular venous distention noted.
LUNGS: Clear.
HEART: Regular rate.
ABDOMEN: Distended with ascites.
EXTREMITIES: He had 1+ thigh edema.
LABORATORY DATA: Yesterday, his BUN was 54, creatinine was 2.6, sodium 130, potassium 5.5, chloride 102, CO2 of 24, AST 46, alkaline phosphatase 362. Albumin was low at 2. Total protein 5.6, calcium 7.8. ALT was 54, amylase was 18, and lipase was normal at 156. CBC, white count of 11.6, hemoglobin of 11.8, and platelets of 306. His BNP was 150. His previous labs were reviewed. It appears that he has had recently an extensive workup for his petechial lesions, most of that was negative. Significantly, he did have positive hepatitis C antibody. His hepatitis B surface antigen was nonreactive. His urinalysis today reveals 1+ protein, 3+ blood, 1+ leukocyte esterase, 10-15 hyaline casts, 20-40 wbc’s, 20-40 rbc’s, and 2+ bacteria.
ASSESSMENT:
1. Acute on chronic renal failure. The etiology could be prerenal azotemia, could be due to urosepsis and resulting acute tubular necrosis. We will also have to consider hepatorenal syndrome. Another possibility is cryoglobulinemic glomerulonephritis as the patient is positive for hepatitis C and also has some skin lesions.
2. Cirrhosis of the liver.
3. Hyperkalemia is due to renal failure and Aldactone use.
4. Diffuse petechial lesions, more prominent on his lower extremities, the etiology is uncertain. Some of them appear like target lesions seen in erythema multiforme, but the patient reports that they have been present since he was a child, but it is unclear if this is reliable history. Another consideration is cryoglobulinemia causing skin lesions, even though the appearance is not a typical purpuric lesion that we find in cryoglobulinemia.
5. History of diabetes.
6. Possible urinary tract infection.
PLAN: At this time, we will administer IV fluids as well as albumin and observe his response. We will obtain urine electrolytes, C3 and C4 complement levels, and cryoglobulin level. Obtain abdominal ultrasound. We will temporarily stop his Aldactone due to the presence of hyperkalemia.
We will continue to follow the patient with you. Thank you, Dr. Doe, for allowing us to participate in the care of this patient.
REFERRING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: Acute renal failure.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old with history of hepatitis C and cirrhosis of the liver. He was sent to the emergency room from the nursing home with a history of painful lower extremities, decreased urine output, and petechial lesions over his extremities. The patient himself is a very poor historian. He also appears to be disoriented to time, and therefore, reliable history could not be obtained from the patient. The nursing home note also suggests that the patient had been confused. Also noted was increased severity of his skin lesions, and the patient had not voided for about 8 hours prior to his transfer to the emergency room.
PAST MEDICAL HISTORY: Significant for cirrhosis of the liver, history of hepatitis C, history of type 2 diabetes, coronary artery disease, hypertension, spinal stenosis, herniated disk, history of osteoarthritis, and benign prostatic hyperplasia.
PAST SURGICAL HISTORY: Includes cholecystectomy, appendectomy, and hernia repair.
MEDICATIONS: In the nursing home included Aldactone 25 mg b.i.d., sliding scale insulin, folic acid, Lortab, Glucotrol XL 10 mg daily, Ativan 1 mg q 6 hours p.r.n., multivitamin, vitamin C, Benadryl, Protonix, Inderal 10 mg daily, and Lasix 20 mg b.i.d. The patient also was on ProMod milkshake.
It also appears that he was admitted just recently, earlier this month. He was discharged with a PICC line for unclear reasons. It appears that the PICC line was removed two weeks ago. He also had a large-volume paracentesis last month.
SOCIAL HISTORY: Unobtainable from the patient. Previous H and P suggests that he has no history of tobacco but is a recovering alcoholic, who has been sober for the past five years.
FAMILY HISTORY: Significant for coronary artery disease.
PHYSICAL EXAMINATION:
GENERAL: The patient is lethargic and confused. He is oriented to place and person but does not remember sequence of events that made him get hospitalized.
VITAL SIGNS: His blood pressure is ranging between 116 and 128 systolic, diastolic between 70 and 84. Pulse is in the 80s. Intake/output recorded as 500 mL in and 120 mL out.
HEENT: Pupils are round and reactive to light.
NECK: Supple. No jugular venous distention noted.
LUNGS: Clear.
HEART: Regular rate.
ABDOMEN: Distended with ascites.
EXTREMITIES: He had 1+ thigh edema.
LABORATORY DATA: Yesterday, his BUN was 54, creatinine was 2.6, sodium 130, potassium 5.5, chloride 102, CO2 of 24, AST 46, alkaline phosphatase 362. Albumin was low at 2. Total protein 5.6, calcium 7.8. ALT was 54, amylase was 18, and lipase was normal at 156. CBC, white count of 11.6, hemoglobin of 11.8, and platelets of 306. His BNP was 150. His previous labs were reviewed. It appears that he has had recently an extensive workup for his petechial lesions, most of that was negative. Significantly, he did have positive hepatitis C antibody. His hepatitis B surface antigen was nonreactive. His urinalysis today reveals 1+ protein, 3+ blood, 1+ leukocyte esterase, 10-15 hyaline casts, 20-40 wbc’s, 20-40 rbc’s, and 2+ bacteria.
ASSESSMENT:
1. Acute on chronic renal failure. The etiology could be prerenal azotemia, could be due to urosepsis and resulting acute tubular necrosis. We will also have to consider hepatorenal syndrome. Another possibility is cryoglobulinemic glomerulonephritis as the patient is positive for hepatitis C and also has some skin lesions.
2. Cirrhosis of the liver.
3. Hyperkalemia is due to renal failure and Aldactone use.
4. Diffuse petechial lesions, more prominent on his lower extremities, the etiology is uncertain. Some of them appear like target lesions seen in erythema multiforme, but the patient reports that they have been present since he was a child, but it is unclear if this is reliable history. Another consideration is cryoglobulinemia causing skin lesions, even though the appearance is not a typical purpuric lesion that we find in cryoglobulinemia.
5. History of diabetes.
6. Possible urinary tract infection.
PLAN: At this time, we will administer IV fluids as well as albumin and observe his response. We will obtain urine electrolytes, C3 and C4 complement levels, and cryoglobulin level. Obtain abdominal ultrasound. We will temporarily stop his Aldactone due to the presence of hyperkalemia.
We will continue to follow the patient with you. Thank you, Dr. Doe, for allowing us to participate in the care of this patient.
