DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: Chronic kidney disease.
HISTORY OF PRESENT ILLNESS: The patient is a pleasant (XX)-year-old woman who has a history of hypertension, diabetes mellitus, and chronic kidney disease, who presented for the purposes of elective laminectomy. The patient had been complaining of worsening right foot drop as well as lumbar and lower back pain. Recent MRI suggests progression of her degenerative changes in the lower lumbar spine as well as severe spinal stenosis.
She underwent lumbar laminectomy, and she tolerated the procedure well. Her systolic blood pressures remained well above 100 mmHg throughout surgery, and her estimated blood loss was approximately 200 mL. She was admitted to the ICU for close monitoring, and during her stay, her blood pressures had been somewhat labile and elevated, which may be directly related to her degree of pain. Her blood pressure at one point was as high as 182/80. Cardiology has been assisting in management of her hypertension, and her hydralazine and metoprolol were both recently increased. Since that time, her blood pressures have been more reasonable.
Her renal function has been stable, and today her creatinine was approximately 2. Her baseline serum creatinine appears to be between 1.6 and 2.4. We are currently being consulted to assist in management of her chronic kidney disease.
PAST MEDICAL HISTORY: Chronic kidney disease, baseline serum creatinine 1.6 to 2.4; hypertension; insulin-dependent diabetes mellitus; diabetic neuropathy; proteinuria, near nephrotic range; gastroesophageal reflux disease; spinal stenosis; degenerative joint disease; hyperlipidemia; rhinitis; and history of vitamin D deficiency.
MEDICATIONS: Current medications include amiodarone 100 mg p.o. daily, Celexa 10 mg p.o. daily, simvastatin 10 mg p.o. q.p.m., lorazepam 0.5 mg p.o. q.h.s., insulin sliding scale, Tylenol 650 mg p.o. q. 6 hours p.r.n., diazepam 5 mg p.o. t.i.d. p.r.n., Colace 100 mg p.o. b.i.d., morphine 1 mg IV push q. 2 hours p.r.n., magnesium hydroxide 10 mL p.o. daily p.r.n., omeprazole 40 mg p.o. daily, Zofran 4 mg IV push q. 6 hours p.r.n., metoprolol 40 mg IV piggyback daily, Norco one tablet p.o. q. 4 hours p.r.n., hydralazine 25 mg p.o. t.i.d., metoprolol XL 50 mg p.o. daily, labetalol 20 mg IV push q. 4 hours p.r.n., and 0.9 normal saline at 80 mL per hour.
ALLERGIES: Multiple, listed in the chart.
FAMILY HISTORY: Negative for chronic kidney disease, including dialysis and transplantation.
SOCIAL HISTORY: No tobacco, alcohol or illicit drug use. She is divorced.
REVIEW OF SYSTEMS: As above, significant for worsening foot drop and weakness to her right lower extremity. She has had ongoing issues with chronic back pain and lumbar pain. She denies any numbness or tingling in her hands or fingers. No shortness of breath, chest pain, palpitations, lower extremity edema, dizziness or syncope. She denies any fever or chills. She denies any bright red blood per rectum or melena. Her vision is not changed, and she is legally blind. She denies any dysuria, flank pain or changes in urinary frequency or urgency. All other systems were reviewed and were negative.
PHYSICAL EXAMINATION:
VITAL SIGNS: Temperature 99.6, heart rate 92, respirations 16, blood pressure 160/70, oxygen saturation 100% on 2 liters nasal cannula.
GENERAL: The patient is in no apparent distress, alert and pleasant, and is oriented x3.
HEENT: Extraocular muscles are intact. Sclerae nonicteric. Mucous membranes are moist.
NECK: Supple with no lymphadenopathy. No jugular venous distention.
LUNGS: Clear to auscultation bilaterally. No crackles, wheezes, rales or rhonchi.
HEART: Regular rate and rhythm. S1, S2 normal with no murmur, rub or gallop.
ABDOMEN: Soft, nontender, and nondistended with normoactive bowel sounds.
EXTREMITIES: No clubbing, cyanosis or edema noted.
LABORATORY DATA: Sodium 138, potassium 4.5, chloride 106, bicarbonate 24, BUN 44, creatinine 2, glucose 266, calcium 7.8. CBC: White blood cell count 11.5, hemoglobin 9.8, hematocrit 29.6, and platelet count 212.
IMAGING STUDIES: Chest x-ray revealed lungs that are clear of infiltrates and heart size is borderline.
IMPRESSION:
1. Chronic kidney disease, stage III/IV, stable.
2. Hypertension, improved.
3. Degenerative joint disease/spinal stenosis, status post lumbar laminectomy and foraminectomy.
4. Diabetes mellitus.
5. Proteinuria.
6. Legally blind.
7. Anemia.
RECOMMENDATIONS: As above, the patient’s creatinine today was 2, and this seems to be right in the middle of her baseline of 1.6 to 2.4. Her blood pressure has responded nicely to increasing her hydralazine as well as increasing her metoprolol, which is also being managed by Cardiology. Indeed, some of her hypertensive issues may be directly related to her degree of ongoing pain post surgery. We will place parameters on her hydralazine, to hold should her systolic blood pressure drop to less than 130, as we wish to avoid any potential hypertensive episodes with her ongoing blood pressure medications in combination with her analgesics. We will continue to monitor renal function very closely while she is in the hospital.
We will place parameters on her hydralazine, to hold should her systolic blood pressure drop to less than 130, as we wish to avoid any potential hypertensive episodes with her ongoing blood pressure medications in combination with her analgesics. We will continue to monitor renal function very closely while she is in the hospital.
Her anemia is noted, with a slight decline in her hemoglobin from 10.6 to 9.8. We will check iron stores and place the patient on iron therapy if necessary. She may require appropriate therapy at this time. We will hold for now assuming her hemoglobin does improve postoperatively.
