DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: Dialysis management.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old African-American female with a past medical history of diabetes type 2; coronary artery disease, status post five-vessel coronary artery bypass surgery with a recent heart catheterization earlier this year that showed patent grafts; end-stage renal disease, on hemodialysis Monday, Wednesday, and Friday. The nephrologist is using a right-tunneled internal jugular venous catheter and an immature left upper extremity graft. The patient also has a history of peripheral vascular disease and CVA. She was admitted to the hospital for chest pain to rule out acute myocardial infarction. The patient reports that following her dialysis, last Wednesday, she developed worsening shortness of breath overnight, and following daytime activity and exertion, she started experiencing nonradiating central chest pain not associated with diaphoresis, nausea or lightheadedness. Therefore, she decided to come to the emergency department. She is pain-free now following her hemodialysis today. This morning, her shortness of breath was much improved. She was seen in consultation with Cardiology who advised maximizing medical management and no further inpatient cardiac workup indicated. Currently, the patient feels better with no shortness of breath, orthopnea, no chest pain, no palpitations, and no dizziness. She has had no nausea or vomiting. She makes minimal urine, and she denies dysuria or hematuria. Review of systems is otherwise unremarkable.
PAST MEDICAL HISTORY: As mentioned above, end-stage renal disease, on hemodialysis; diabetes mellitus type 2; hypertension; coronary artery disease, status post five-vessel coronary artery bypass, status post negative Myoview test last December and heart catheterization that showed patent graft earlier this year; history of peripheral vascular disease; and history of CVA.
PAST SURGICAL HISTORY: Cesarean section and multiple herniorrhaphies. History of left upper extremity arteriovenous fistula, last August, remains immature.
HOME MEDICATIONS: The patient is on Norvasc, Zocor, metoprolol, Aggrenox, Plavix, minoxidil, Diovan, Prevacid, Imdur, Procardia, and Darvocet.
ALLERGIES: No known drug allergies.
FAMILY HISTORY: Not contributory to renal evaluation.
SOCIAL HISTORY: The patient lives at home with family. The patient denies tobacco or alcohol use.
PHYSICAL EXAMINATION:
GENERAL: The patient is currently not in apparent distress. She is alert and oriented x3.
VITAL SIGNS: Blood pressure 146/66, heart rate 88, oxygen saturation 94% on room air.
HEENT: Atraumatic and normocephalic. No scleral icterus. Pupils are equal, round and reactive to light. Extraocular movements are intact. Oropharyngeal examination is unremarkable.
NECK: Shows no JVD, no lymphadenopathy, no carotid bruits, no thyromegaly.
LUNGS: Clear to auscultation bilaterally.
CARDIAC: Regular rate and rhythm. Audible S1, S2. No murmur, rub or gallop.
ABDOMEN: Soft, nontender. No palpable masses. No organomegaly. Bowel sounds are positive. No costovertebral angle tenderness.
EXTREMITIES: Show 1+ pitting edema. Decreased dorsalis pedis and posterior tibial artery pulsations bilaterally.
NEUROLOGICAL: Examination is grossly nonfocal.
LABORATORY DATA: Laboratories from yesterday showed hemoglobin of 12.4, normal white blood count and platelet count. Her electrolytes are within normal limits. BUN is 21, creatinine is 5.6, and albumin is 4. Cardiac enzymes x2 are negative. Urinalysis showed 3+ albumin, 2+ occult blood, 3+ leukocyte esterase, and 20-50 wbc’s with 1+ bacteria. Her TSH is normal.
DIAGNOSTIC DATA: Chest x-ray showed cardiomegaly, otherwise unremarkable findings.
IMPRESSION:
1. End-stage renal disease, on hemodialysis.
2. Chest pain ruled out for acute myocardial infarction. Rule out noncardiac causes.
3. Fluid overload.
4. Uncontrolled hypertension, largely secondary to fluid overload.
5. Diabetes mellitus type 2.
6. Coronary artery disease, status post coronary artery bypass graft with patent grafts per cardiac catheterization done earlier this year.
7. History of peripheral vascular disease with immature left upper extremity arteriovenous fistula.
PLAN: We have postponed her discharge today due to significant fluid overload and uncontrolled hypertension. The patient will benefit from repeat dialysis tomorrow to achieve dry weight and prevent recurrence of shortness of breath and chest pain. We have also asked the GI team to evaluate for noncardiac causes for chest pain. In the meantime, continue pantoprazole and famotidine. We might be able to discontinue some of the direct vasodilators and antihypertensive medications with adequate fluid removal at dialysis. Further recommendations as the clinical status and laboratory results might dictate.
