DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: Evaluation and management of end-stage renal disease, on hemodialysis.
HISTORY OF PRESENT ILLNESS: This is a very pleasant (XX)-year-old female, who is undergoing dialysis. The patient states that she went to the dialysis unit today, complaining of some shortness of breath and had a hematocrit run, which showed that it was very low. This test was repeated, and her hemoglobin was 6 in the emergency department today. She was asked to come directly to the emergency room without dialysis for possibility of bleeding. She has a past medical history of homozygous sickle cell disease leading to end-stage renal disease, sickle cell hepatopathy, hypertension, multiple failed vascular accesses, a right PermCath, which was infected the last time she was hospitalized but was able to be saved with antibiotics. The patient was seen in emergent consultation in the emergency room after being on vancomycin for 6 weeks for sepsis syndrome and consultation is further requested regarding her condition.
REVIEW OF SYSTEMS: The patient denies chest pain or palpitations. She is quite short of breath, otherwise states she feels well. The patient has not had fever, chills, cough, chest pain, abdominal pain, nausea, vomiting, diarrhea, black or bloody stools. The patient does complain of right hip pain and back pain and states that she may have fallen recently.
MEDICATIONS AT HOME: Cardizem, clonidine, and PhosLo.
PAST MEDICAL HISTORY: End-stage renal disease, homozygous sickle cell, PermCath, failed vascular accesses, severe hypertension, and sickle cell hepatopathy.
SOCIAL HISTORY: Nonsmoker, nondrinker.
FAMILY HISTORY: Negative for inherited renal disease.
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure is currently 142/64, pulse 60, and afebrile.
HEENT: Head normocephalic. No mass or tenderness. Slight scleral icterus. Pupils symmetric. Sclerae anicteric.
NECK: No JVD, no thyromegaly.
CHEST: Right chest PermCath does not appear infected.
LUNGS: Clear to auscultation and percussion. Symmetric excursions.
HEART: Normal S1 and S2 with 3/6 systolic ejection murmur at the base of the heart.
ABDOMEN: Soft, nontender, and nondistended. Positive bowel sounds.
EXTREMITIES: No clubbing, cyanosis or edema.
SKIN: No rashes, warm, and dry.
NEUROLOGIC: Alert and oriented x3. Cranial nerves intact.
LABORATORY AND DIAGNOSTIC STUDIES: Hemoglobin 6. Howell-Jolly bodies consistent with autosplenectomy. Platelets 444,000, mean corpuscular hemoglobin 28.8, mean cell volume 91.4 with somewhat of an eosinophilic predominance. RBC mass 2.06, reticulocyte count 4, which is elevated.
ASSESSMENT:
1. Acute shortness of breath, likely secondary to anemia.
2. History of acute anemia, history of sickle cell homozygous disease with worsened anemia, unclear etiology. The patient denies bleeding gums, petechiae, purpura, bright red blood per rectum.
3. History of PermCath infection, on vancomycin.
4. End-stage renal disease dialysis Tuesday, Thursday, and Saturday. Multiple failed vascular accesses.
5. Right hip pain, suspected history of fall and trauma in the past.
PLAN:
1. Right hip x-rays.
2. Mobile dialysis to dialyze today.
3. Transfuse 3 units of packed red blood cells.
4. Hematology consult regarding homozygous sickle cell.
5. Renal osteodystrophy panel.
