DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: Renal failure and digoxin toxicity.
HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old Hispanic male with a history of St. Jude 31 aortic valve replacement secondary to severe aortic insufficiency with associated left ventricular dysfunction, EF of 25% at that time. His postoperative course was reportedly complicated by pericardial effusion that required pericardiocentesis. His most recent echocardiogram, two years ago, revealed an ejection fraction of 60% with normal function of the aortic valve prosthesis. He was seen in the clinic yesterday with progressive exertional dyspnea, vague chest discomfort, progressive lower extremity swelling, and occasional dyspnea and orthopnea. He was found to be in congestive heart failure. An echocardiogram performed in the office showed atrial fibrillation with complete heart block with junctional escape and parasystolic foci. He was then referred to the emergency department for further evaluation of suspected digoxin toxicity.
Of note, he remained hemodynamically stable with blood pressure 160s to 190s, while in the clinic. His digoxin level today is 4.6. He remains in complete heart block with junctional escape and parasystolic beat with heart rate of 60s and blood pressure 146/72. He is also noted to have supratherapeutic INR of 13.4, and received vitamin K 5 mg p.o. last night. Currently, he denies any chest pain. He is dyspneic and notes that his urine output has decreased. His father is present in the room, and he notes that the patient had an IVP done three days ago. The patient is unclear whether or not he had an IVP, but he thinks he had some renal evaluation three days ago. The patient denies any hematuria. No evidence of GI bleed or any other bleeding source.
PAST MEDICAL HISTORY: Status post aortic valve replaced by mechanical valve in the past, hypertension, dyslipidemia, and diabetes.
MEDICATIONS: Home medicines include furosemide 40 mg daily, Lanoxin 250 mcg one by mouth daily, Lantus 100 units at bedtime, Lipitor 20 mg daily, metoprolol 50 mg b.i.d., quinapril 40 mg twice daily, verapamil SR 240 mg daily, and warfarin 5 mg daily.
FAMILY HISTORY: Significant for cardiovascular disease and diabetes.
SOCIAL HISTORY: Denies any alcohol or tobacco use.
REVIEW OF SYSTEMS: As above.
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 146/72 and heart rate 50s.
GENERAL: A well-developed, well-nourished male in no acute distress. Alert and oriented x3. He is somewhat sluggish but answers the questions appropriately.
HEENT: Pupils are equal, round, and reactive to light. Extraocular movements are intact. Oropharynx is clear.
NECK: Supple. There is significant jugular venous distention. Carotid pulses are normal without any carotid bruits.
LUNGS: Slightly decreased breath sounds at the bases with good air movement. No crackles or wheeze audible.
HEART: Regular rhythm with frequent ectopic beats. PMI is minimally displaced. A crisp mechanical aortic valve is audible. A soft systolic ejection murmur audible at the base.
ABDOMEN: Distended with possible ascites. Nontender. Unable to palpate for organomegaly due to abdominal distention.
EXTREMITIES: Have 3 to 4+ pitting edema.
NEUROLOGICAL: Exam is nonfocal.
LABORATORY DATA: INR 13.4, hematocrit 35.6, platelets 276, and white count 7.6. Creatinine 3.6, BUN 36, glucose 134, potassium 4.2, digoxin 4.6. BNP is greater than 4000.
DIAGNOSTIC DATA: Chest x-ray shows cardiomegaly without any effusions. There are increased interstitial markings noted.
IMPRESSION:
1. Arrhythmia secondary to digoxin toxicity.
2. Renal failure, probably acute on chronic.
3. Congestive heart failure with anasarca.
4. Coumadin toxicity, probably secondary to hepatic congestion.
5. No current evidence of bleeding.
PLAN: We will discuss with the nephrologist regarding possible dialysis. We will give the patient fresh frozen plasma and vitamin K IV due to risk of thrombosis in a patient with mechanical aortic valve. Discontinue all negative chronotropic medications, including metoprolol and diltiazem. Discontinue quinapril due to renal failure. We will obtain an echocardiogram and evaluate cardiac function and valvular function. We agree with obtaining TSH level and LFT. The patient needs close monitoring of his INR. We will give Lasix posttransfusion and fresh frozen plasma.
