DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: Renal failure, oliguria.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old female who has multiple medical problems, who was transferred here because of altered level of consciousness. The patient has problems, which started back in January when she had a prolonged hospitalization course. The patient had cardiac arrest at that time and acute renal failure for which she needed temporary dialysis. The patient was off dialysis, and her creatinine had been stable since. She also has a history of osteomyelitis of the right toe and had vertebral osteomyelitis and epidural placement. The patient had been admitted to an outside facility, and she has not been well for the past few days and recently has been diagnosed with Clostridium difficile colitis about a week ago. She was treated with antibiotics over there. She has been progressively getting worse with loose stool, and yesterday, she got worse with altered mental status and low blood pressure for which she was transferred here. In the ER, the patient was found to be very hypotensive. Her blood pressure, systolic, was in the 60s and 70s. She had received fluid bolus and was started on pressor support. She has received 2 or 3 liters of fluid bolus and is on pressor support with blood pressure, systolic, in the range of 90s and 100s. Her laboratory showed high BUN and creatinine and also she is not making much urine, which prompted renal consultation. Her laboratory about a week ago showed creatinine was within normal range. Currently, she is admitted to ICU and she is DNR with full active treatment.
PAST MEDICAL HISTORY: Significant for hypertension, history of diabetes, history of cardiac arrest, acute renal failure needing dialysis in January, history of recent Clostridium difficile colitis about a week ago, history of osteomyelitis, and staphylococcus infection in the past.
PAST SURGICAL HISTORY: She had left L3-4 laminectomy with epidural abscess drainage in July.
ALLERGIES: No known allergies.
MEDICATIONS: She has been on multivitamin, Norvasc, Remeron, aspirin, fentanyl, Lasix, Imdur, Lactinex, and oxycodone.
SOCIAL HISTORY: She has a history of smoking about 6 to 7 cigarettes per day. No alcohol use.
FAMILY HISTORY: Noncontributory.
REVIEW OF SYSTEMS: As per HPI. Most of the information is obtained from the chart and review of chart.
PHYSICAL EXAMINATION:
GENERAL: On examination, this is an elderly female who is lethargic and arousable.
VITAL SIGNS: Now, blood pressure is 102/62, heart rate is 88, and temperature is 97.4 degrees.
HEENT: Normocephalic and atraumatic. Pupils are reacting sluggishly. She has got NG tube in place.
NECK: Supple.
LUNGS: Bilateral air entry with some diminished breath sounds at the bases.
HEART: Sounds are regular with no murmur noted.
ABDOMEN: Tender all over, mildly distended. Bowel sounds are diminished.
EXTREMITIES: Show no edema.
NEUROLOGIC: Examination not done at this time.
SKIN: Dry, intact.
LABORATORY AND DIAGNOSTIC DATA: White count is 60, hemoglobin 10.3, hematocrit 31.6, and platelets 466. Her sodium is 129, potassium is 5.5, chloride is 96, bicarbonate is 15, glucose 196, BUN/creatinine 82 and 3.4. BNP is 150. CT of the brain shows no acute changes.
IMPRESSION:
1. A patient with altered mental status, likely toxic metabolic encephalopathy.
2. Sepsis syndrome with septic shock with low blood pressure, on pressors.
3. Oliguric renal failure.
4. Acidosis.
5. Marked leukocytosis.
6. Recent Clostridium difficile colitis.
7. History of methicillin-resistant Staphylococcus aureus infection and bacteremia.
8. History of cardiac arrest and acute renal failure in January.
9. History of chronic left bundle branch block.
RECOMMENDATIONS: Acute renal failure, likely secondary to the above, likely secondary to sepsis and volume depletion and medication use with possibility of going into ATN. At this time, agree with fluid resuscitation and pressor support. The patient is acutely ill at this time. She has been started on broad-spectrum antibiotic coverage. We will repeat her chemistry and follow up on the potassium level and add bicarbonate as needed. Cultures have been ordered. We have discussed the case with the family, and we will dialyze the patient if needed. No need of dialysis at this point. We will follow closely. Further recommendations and plans as we go along.
Thank you for the consultation and for allowing us to participate in this patient’s care.
