Case Study 8 Consult Essays

Case Study 8 Consult Essays Case Study 8 Consult Paper Case Study 8 Consult Paper CONSULTATION REASON FOR CONSULT: Acute on chronic renal failure. Patient is an 87 year old Caucasian male who has a history of hypertension, severe peripheral vascular disease, chronic renal insufficiency, and atrial fibrillation. He was admitted yesterday for treatment of an infected toe. The plan was to obtain an angiogram to check patients’ blood flow; however he was discovered on admission labs to have acute on chronic renal failure, patient states he is unaware of kidney problems before. He states he is able to pass his urine without difficulty, no obstructive symptoms, no history of kidney stones, no urinary tract infections, no hematosis, no dysuria, and no diabetes mellitus. Patient states he has a history of hypertension, but it has been very mild. He has had trouble with vascular disease to both legs. Patients’ base line serum creatinine is 1.5 to 1.7, patients laboratory studies from this morning indicates a BUN of 101 and a creatinine of 3.9. ALLERGIES: Penicillin which causes anaphylactic shock. CURRENT MEDICATIONS: Lanoxin, furosemide, Zocor, Prinivil, diltiazem, pentoxifyline, and as needed pain medications. PAST HISTORY: Significant for hypertension, severe peripheral vascular disease, chronic atrial fibrillation, on Coumadin. History of the left carotid endarterectomy, history of CHF, status post cataract surgery and amputation of the right great toe. SOCIAL HISTORY: Past history of both tobacco abuse and alcohol abuse. FAMILY HISTORY: Never before any kidney disease. Brother has diabetes mellitus. (Continued) CONSULTATION PATIENT NAME: Chapman Robert Kinsey PATIENT ID: 110589 DATE OF CONSULT: 02/24/- Page 2 REVIEW OF SYSTEMS: Patient notes he has otherwise felt fine. He has no rashes. He has a good appetite, no nausea or vomiting, no abdominal pain, no chest pain or shortness of breath. No lower extremity edema. He is incontinent of stool. PHYSICAL EXAMINATION: General: An elderly male in no acute distressful stop. Vital Signs: Temperature 98.3 Pulse 63 Blood Pressure 96/58 Respiration 24. HEENT: PERRLA, oropharynx clear, bilateral hearing aids. Neck: No JVD. No carotid bruits. LUNGS: Clear to auscultation bilaterally. CARDIOVASCULAR: Irregularly irregular. ABDOMEN: Soft, non-tender, no distended. EXTREMITIES: With no lower extremity edema. He has a first toe amputation on the right. He has a bandage on his first toe on the left and changes of chronic blood flow. Laboratory studies from today show a C-reactive protein of 47. White blood cell 9.8, hemoglobin 13.5, hematocrit of 39.8 and platelets of 198,000, sed rate 57, sodium 140, potassium 5.5, chloride 115, bicarb 14, glucose 99, BUN 101, creatinine 3.9, calcium 8.3, and albumin 4.9. ASSESSMENT 1. Acute renal failure of unclear etiology. Recheck multiple studies. 2. Chronic renal failure with a baseline creatinine of 1.5 to 1.7. 3. Hyperkalemia secondary to acute renal failure. 4. Metabolic acidosis, also secondary acute renal failure. 5. Slight volume depletion. (Continued) CONSULTATION PATIENT NAME: Chapman Robert Kinsey PATIENT ID: 110589 DATE OF CONSULT: 02/24/- Page 3 PLAN RECOMMENDATION 1. I would recommend waiting on the angiogram secondary to his acute renal failure, as this would exacerbate the condition. 2. Discontinue medications that could possibly cause or worsen his acute renal failure, such as his Prinivil and diuretic. 3. Renal dose all medication for a creatinine clearance of 0. 4. Start intravenous fluid at a low rate. 5. Obtain renal ultrasound. 6. Obtain urinary studies. 7. Obtain serum studies. 8. Restrict all potassium intakes. 9. Start Bicitra for his metabolic acidosis. 10. If studies are unrevealing, patient potentially may need kidney biopsy. 11. If he does not recover, he will need to start dialysis. Thank you Dr. Eaton, for allowing me to participate in the care of this pleasant patient. I will follow along with you as needed. __________________________________________ Trevor Jordan, MD, Nephrology TJ: D:02/24/- T:02/24/-