DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION:
1. Hypertensive urgency.
2. Renal failure, probably acute on chronic.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old Hispanic female with past medical history of hypertension, chronic kidney disease, possibly due to hypertensive nephrosclerosis in addition to renal artery stenosis, bilateral 25-50% stenosis 3 years ago. The patient had a creatinine clearance of 27 mL/minute 3 years ago and also past medical history of hyperlipidemia and normal left ventricular ejection fraction 3 years ago. The patient reports a history of progressive shortness of breath associated with epigastric pain, wheezing, cough with mucoid sputum for the past 1 week or so. She initially visited the cardiologist last week for evaluation of these symptoms and was found to have angina equivalent dyspnea with abnormal EKG and also uncontrolled hypertension with a blood pressure of 190/140.
The patient was advised to go to the emergency department immediately; however, the patient apparently refused them, and therefore, she was advised outpatient treatment and followup. She came in yesterday to the emergency department due to worsening symptoms. The patient denies fever or chills. She is not aware of prior renal disease. The patient had serum creatinine of 2.2 on discharge from the hospital 3 years ago, during which hospitalization she had multiple issues including anemia without GI source, worsening renal failure, and uncontrolled hypertension. She is on weekly Procrit injections since earlier this year, and her anemia remains corrected. She is not on diuretics but is on angiotensin receptor blocker, Benicar, and beta blockers, Toprol XL, which was changed to labetalol by the cardiologist 1 week ago.
The patient reports that she has constant epigastric pain that is associated with shortness of breath, which is apparently not exertional. She does not have orthopnea or PND. No palpitations. No lightheadedness or dizziness. No diaphoresis. No nausea or vomiting. No abdominal pain otherwise. She does not have any history of melena or hematochezia. She does not have any urinary complaints such as dysuria, frequency or hematuria. She reports swelling of her legs whenever she is standing or sitting for a long time; otherwise, she does not have significant leg edema. The patient denies headache, weakness in the extremities or visual complaints.
PAST MEDICAL HISTORY:
1. Longstanding hypertension, apparently with poor control.
2. Renal artery stenosis based on prior admission for uncontrolled hypertension 3 years ago and an MRA that showed bilaterally small kidneys with asymmetry, small left renal size of 7.4 cm. Study showed bilateral renal artery stenosis of 25-50%.
3. Chronic kidney disease with proteinuria, probably hypertensive and ischemic in etiology; however, we cannot rule out other causes. The patient is not known to be diabetic.
4. Hyperlipidemia, not on statins.
5. Osteoarthritis.
PAST SURGICAL HISTORY: Hysterectomy.
HOME MEDICATIONS: Benicar 20 mg p.o. daily, Toprol-XL 50 mg b.i.d. which was changed to labetalol by cardiologist recently, aspirin, Procrit 20,000 units subcutaneously every week started earlier this year, and nitroglycerin tablet p.o. p.r.n. started 1 week ago by the cardiologist.
ALLERGIES: No known drug allergies.
FAMILY HISTORY: Unremarkable for renal disease. Questionable history of coronary artery disease in family members.
SOCIAL HISTORY: The patient lives with family. The patient denies tobacco, alcohol or drug use.
REVIEW OF SYSTEMS: As mentioned above in history of present illness, otherwise unremarkable.
PHYSICAL EXAMINATION:
GENERAL: The patient is alert and oriented x3. She is not in apparent distress.
VITAL SIGNS: The patient’s vitals included blood pressure of 200/112, pulse rate of 62, oxygen saturation 97% on room air, and respiratory rate of 18. She is afebrile. Her body weight is 139.5 pounds. Urine output is 700 mL for the past 16 hours.
HEENT: Atraumatic, normocephalic. No scleral icterus. Pupils are equal, round, and reactive to light. Intact extraocular movements. Oropharyngeal examination is unremarkable.
NECK: No evidence of jugular venous distention. No carotid bruits, no thyromegaly, no lymphadenopathy.
LUNGS: Clear to auscultation bilaterally.
HEART: Regular rate and rhythm. Normal S1, S2. No murmur, rub or gallop.
ABDOMEN: There is marked epigastric deep tenderness without rebound or guarding. There is no organomegaly or palpable masses. No costovertebral angle tenderness. Bowel sounds are positive. There are no abdominal bruits.
EXTREMITIES: Trace edema bilaterally. Dorsalis pedis and posterior tibial are good bilaterally.
NEUROLOGIC: Grossly nonfocal.
LABORATORY DATA: Admission labs show leukopenia with a total white cell count of 2000, hemoglobin 15.2, normal platelets. D-dimer is elevated at 0.61. Cardiac isoenzymes are negative x3. Electrolytes are normal. BUN is 60 and creatinine is 3.8 which is down from 4.1 yesterday. Albumin is 3. LFTs are abnormal with mildly elevated transaminases. Urinalysis shows 2+ albumin, otherwise unremarkable. BNP is elevated at 2540. Chest x-ray shows cardiomegaly with bilateral interstitial infiltrate, which is new compared to prior films in addition to bibasilar infiltrates and right pleural effusion. V/Q scan was low probability for pulmonary edema. Renal ultrasound is pending.
ASSESSMENT:
1. Hypertensive urgency. The patient was started on atenolol, nitroglycerin paste and Bumex at 2 mg IV b.i.d. since admission.
2. Bilateral renal artery stenosis.
3. Chronic kidney disease secondary to hypertension and renal artery stenosis/ischemic nephropathy. Creatinine clearance was 27 mL/minute 3 years ago.
4. Probable acute-on-chronic renal insufficiency secondary to Benicar versus natural progression of chronic kidney disease.
5. Mild fluid overload/pulmonary congestion, currently on Bumex.
6. Angina equivalent shortness of breath with abnormal EKG and negative chest pain panel x3. The patient had normal left ventricular ejection fraction 3 years ago. Cardiology consult is pending.
7. Right pleural effusion.
8. Leukopenia, of unclear etiology.
9. History of hyperlipidemia.
10. Anemia, on Procrit.
PLAN: The patient remains with high blood pressure profile despite diuretics and beta blockers and nitroglycerin. We have added schedule doses of clonidine in addition to Norvasc. The patient is not in cardiac decompensation and manifests mild evidence of fluid overload without respiratory compromise. Therefore, at this stage, we are against aggressive diuresis, which might worsen renal function given the underlying renal artery stenosis. Strict I’s and O’s and daily body weights would help in managing her fluid status at this point. Renal Doppler to re-evaluate for renal artery stenosis is ordered. We preferred this study over MRA due to the emergent incidence of nephrogenic fibrosing dermopathy secondary to gadolinium. If renal Doppler reveals inconclusive results, then we might resort to MRA instead. Urine indices to quantify proteinuria and peripheral smear to assess for leukopenia is also ordered. Close monitoring of blood pressure and renal function is undertaken. Further recommendations pending clinical status and lab results.
