DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: Acute renal failure.
Thank you for allowing us to participate in the care of this patient. We are asked to evaluate this patient for an elevated serum creatinine of 2.3 mg/dL at the time of evaluation today. He has a known history of chronic kidney disease with baseline serum creatinine values of 1.8-1.9 mg/dL as far back as January (XXXX).
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old Hispanic male with history of extensive emphysema, chronic tobacco use, and questionable history of liver disease who was admitted with shortness of breath and is currently being treated for chronic obstructive pulmonary disease exacerbation and pneumonitis. We are asked to evaluate regarding elevated serum creatinine.
The patient has chronic kidney disease. The etiology at this time is still unclear. He has had serum creatinine values of 1.8-1.9 mg/dL as far back as January (XXXX). Over the last 24 hours, there has been noted increase in his serum creatinine from his baseline of 1.9 mg/dL to 2.3 mg/dL. Only new event has been the development of diarrhea. He reports 2 to 3 loose stools. There has been no associated nausea or vomiting. He did have a CT scan; however, this was without contrast. There is no new potentially nephrotoxic medication that has been started.
PAST MEDICAL HISTORY: History is negative for hypertension. He denies history of diabetes. He denies chronic nonsteroidal anti-inflammatory drug use, and he denies recurrent urinary tract infection.
PAST SURGICAL HISTORY: Notable for appendectomy.
PREHOSPITAL MEDICATIONS: Inhalers.
CURRENT MEDICATIONS: Protonix 40 mg daily, Lovenox 40 mg subcutaneously daily, Megace 400 mg daily, Medrol 60 mg IV q. 6 hours, azithromycin q. 24 hours, ceftriaxone 1 gram q. 24 hours, albuterol and terbutaline as needed.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: Positive for heavy tobacco use. He is down to 1 pack per day. He denies illicit drug use. He does give a history of prior blood transfusions.
FAMILY HISTORY: Negative for kidney disease or diabetes.
LABORATORY DATA: Sodium 138, potassium 4.2, BUN 41, creatinine 2.3, chloride 111, and bicarbonate 24. WBC 12.2, hemoglobin 11.4, and platelets 188,000. Magnesium 2.5 and phosphorus 2.6. CPK was 284 on admission. He has no available urinalysis for review at this time.
DIAGNOSTIC DATA: The patient’s chest x-rays showed emphysematous changes. A noncontrast CT of thorax showed DJD of the spine, extensive chronic interstitial disease, and emphysematous changes of both lungs and prior granulomatous disease. He did obtain a renal ultrasound, which showed bilateral echogenic kidneys of 9.3 and 9.6 cm right and left respectively without obstruction or masses.
PHYSICAL EXAMINATION:
GENERAL: The patient is alert and oriented x3.
VITAL SIGNS: He is afebrile. Blood pressure 138/78, tachycardic t 118 per minute, and respirations 26.
HEENT: The patient is without clinical pallor or icterus. Ears: TMs intact.
NECK: Supple. No lymphadenopathy or bruits.
LUNGS: Lung fields with diminished air entry, bilateral rhonchi.
HEART: Tachycardic. No rubs.
ABDOMEN: Soft. No masses. No demonstrable ascites.
EXTREMITIES: No lower extremity edema, cyanosis, clubbing or appreciable rash.
NEUROLOGIC: The patient is alert and oriented x3 without focal deficits.
ASSESSMENT AND RECOMMENDATIONS: Overall, this is a (XX)-year-old male with:
1. Nonoliguric acute renal failure that is superimposed on underlying chronic kidney disease stage III. Etiology of his acute renal failure, rule out prerenal based on new-onset diarrhea, rule out acute interstitial nephritis. Also, his ejection fraction is yet to be determined, to rule out CHF and diminished effective arterial volume. Recommendation at this time is to continue IV hydration with 0.9 saline. Let us obtain urinary electrolytes. No evidence of obstruction, as noted above, on his kidney on ultrasound. The etiology of his chronic kidney disease is also still unclear. He has no history of hypertension or diabetes. There is a remote history of liver disease, which is unclear. Let us obtain the following laboratory data in workup of his chronic kidney disease. Let us establish proteinuria by random urine protein/creatinine ratio, hepatitis B and C serology, HIV serology, serum protein electrophoresis, and monoclonal protein electrophoresis as well as ANA complements and rheumatoid factor.
2. Anemia of chronic disease. Check iron parameters to evaluate iron and the need for iron replacement.
3. Rule out secondary hyperparathyroidism and vitamin D2 deficiency. Let us obtain an intact parathyroid hormone level as well as vitamin D, 25 hydroxy, levels. His calcium, phosphorus as outlined above is acceptable, and there is currently no metabolic acidosis.
4. Chronic obstructive pulmonary disease exacerbation/pneumonitis, ongoing medical/pulmonary management.
5. Smoking cessation counseling.
6. Add renal formulated multivitamin daily.
