DATE OF ADMISSION: MM/DD/YYYY
DATE OF DISCHARGE: MM/DD/YYYY
FINAL DIAGNOSES:
1. Volume overload secondary to end-stage renal disease.
2. Chronic rejection of cadaveric renal transplant.
3. Anemia.
4. Hypertension.
5. Urinary tract infection.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old Hispanic female with a past medical history of end-stage renal disease secondary to reflux, status post cadaveric renal transplant 15 years ago with chronic rejection of the transplant kidney for the last few years and recent creatinine levels of 6. Over the last few days, the patient complained of exertional dyspnea, orthopnea, PND, and bilateral leg swelling, which were worsening. Otherwise, review of systems was negative.
PAST MEDICAL HISTORY: End-stage renal disease secondary to reflux, status post cadaveric renal transplant 15 years ago with chronic rejection of the transplant kidney over the last few years, and hypertension.
PAST SURGICAL HISTORY: Tubal ligation, surgical fistula in the left arm earlier this year, and cadaveric renal transplant.
MEDICATIONS: The patient was taking Prograf 5 mg b.i.d., Imuran 100 mg at bedtime, prednisone 5 mg daily, Procardia XL 60 mg b.i.d., Lasix 80 mg daily, Lipitor 10 mg daily, iron supplements b.i.d., Os-Cal b.i.d., and Aranesp 100 mcg subcutaneously weekly.
ALLERGIES: The patient was allergic to vancomycin.
PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 97.8 degrees, pulse 92, respiratory rate 22, blood pressure 152/82, and O2 saturations of 99% on room air. GENERAL: The patient appeared mildly anxious, in mild respiratory distress. She was awake, alert, and oriented x3. HEENT: Conjunctival pallor. Pupils were equal, round, and reactive to light. Extraocular movements were intact. NECK: JVD was present. HEART: Regular rate and rhythm with normal S1 and S2, no rub. LUNGS: Bilateral crackles half way up the lung fields with dullness to percussion at the right base. ABDOMEN: Soft, obese, nontender, and nondistended. EXTREMITIES: Showed +3 pitting edema bilaterally. NEUROLOGIC: No focal deficits.
LABORATORY AND DIAGNOSTIC DATA: White count 4800, hemoglobin 6.9, hematocrit 21, and platelets 186,000. MCV was 102. Sodium 141, potassium 5.2, chloride 112, bicarbonate 14, BUN 66, creatinine 6, and glucose 90. Total bilirubin was 0.2. LFTs were within normal limits. INR was 1.1. The patient had a renal ultrasound, which revealed minimal fullness of the upper pole collecting system. Chest x-ray showed mild CHF with a small right pleural effusion. EKG showed normal sinus rhythm, tachycardia, and flat T waves in III, aVF, and V6.
HOSPITAL COURSE: The patient was admitted for treatment of volume overload. She was treated with IV Lasix 80 mg three times daily with metolazone 5 mg twice daily. She was also noted to have a UTI with moderate blood, large leukocyte esterase, and positive nitrites with many white blood cells. She was treated with one dose of IV Levaquin followed by 250 mg of p.o. Levaquin daily. Urine culture results were not available at the time of discharge.
The patient underwent anemia workup as well, which included iron of 72, TIBC of 146, ferritin 204, haptoglobin 23, and LDH 304. After being treated with Lasix, the patient diuresed well and lost a total of 6 pounds total. Her creatinine decreased from 6 to 5.7 and potassium was 4.2. She did not require hemodialysis. She felt better and was transfused one unit of packed RBCs prior to discharge. She also received two doses of Procrit.
An echocardiogram was done, which showed a good left ejection fraction, LVH, small pericardial effusion, and a dilated left ventricle. A 24-hour urine for creatinine clearance was done during the admission; however, the final results were not available at the time of discharge. The patient had no shortness of breath on discharge.
DISCHARGE INSTRUCTIONS: The patient was given prescriptions for Levaquin 250 mg p.o. daily as well as Lasix 80 mg p.o. b.i.d. and metolazone 5 mg b.i.d. The patient should follow up in the renal clinic next week for repeat urinalysis and urine culture results.
