DATE OF ADMISSION: MM/DD/YYYY
DATE OF DISCHARGE: MM/DD/YYYY
PRIMARY DIAGNOSES:
1. Acute renal failure.
2. Anemia of chronic disease.
DISCHARGE DIAGNOSES:
1. Acute renal failure.
2. Anemia of chronic disease.
3. Urinary tract infection.
4. Hyperkalemia.
5. Atrial fibrillation.
6. Lupus.
7. Gastroesophageal reflux disease.
8. Hypothyroidism.
9. Osteopenia.
CONSULTANTS: Nephrology.
STUDIES:
1. Bilateral renal ultrasound revealed normal kidneys bilaterally without focal lesions, hydronephrosis or cortical abnormalities.
2. Urinalysis with 2+ bacteria and 5 white blood cells as well as urine culture greater than 100,000 colony-forming units of gram negative rods.
LABORATORY DATA: Electrolytes on admission: Sodium 144, potassium 6.6, chloride 109, CO2 of 15, BUN 84, creatinine 5.6, glucose 98, magnesium 2.0, phosphorus 5.6. LFTs on admission were within normal limits. Coags on admission: INR 2.0, PT 22.8, PTT 32. CBC on admission: White blood cell count 6.4, hemoglobin 10, hematocrit 29.2, and platelets 198. Electrolytes upon discharge: Sodium 144, potassium 4.4, chloride 111, CO2 of 21, BUN 68, creatinine 4.8, glucose 86. Coags on discharge: INR 1.8. CBC on discharge: White blood cell count 5.4, hemoglobin 8.4, hematocrit 24.4, and platelets 172. Iron studies: Iron level 92, TIBC 224, iron saturation 40, ferritin 398, reticulocyte count 1.4%, folate greater than 24.0, vitamin B12 of 628. Hemolysis studies: Haptoglobin 156, LDH 614, ESR 70, CRP 0.9. Urine studies: Urine eosinophils 0%. Rheumatology labs: ANA none detected, antismooth muscle antibody 15, complement C3 of 116, complement C4 of 26. Note that SPEP/UPEP, parathyroid, antidouble stranded DNA, antiglomerular basement membrane antibody, lupus anticoagulant, ANCA antibodies are pending. TSH less than 0.06, free T4 of 1.44. Lipid profile: Cholesterol 192, LDL 120, HDL 42, triglycerides 150. Urine electrolytes: Sodium 109, potassium 21.2, and chloride 97.
HISTORY OF PRESENT ILLNESS: The patient was admitted after presenting to her primary care physician a day prior to admission with a two-month complaint of gradual decline in energy, increased fatigue needing to sleep throughout the day and not being able to participate in her regular activities. Her primary care physician did several surveillance labs at the time of her visit.
She was noted on the surveillance labs to have a creatinine of 6.26 and a BUN of 84. The patient had previously had normal renal function with a creatinine of 1.1 seven months back. The patient was also noted to have a potassium of 6.7. Upon receipt of these laboratory values, the patient was instructed by her primary care physician to come to the emergency department where she was admitted to the medicine service for management of her acute renal failure, hyperkalemia, and anemia.
The patient was also noted in the emergency department to have a urinary tract infection and was treated with Levaquin throughout her hospitalization.
HOSPITAL COURSE BY PROBLEMS:
1. Acute renal failure: The patient was treated with very gentle hydration, and a renal consult was obtained. A renal ultrasound was done to rule out obstructive causes. Urine electrolytes were obtained. Urinalysis and urine sediment was obtained. Throughout the patient’s hospital course, her creatinine gradually improved without intervention from 5.6 on admission to 4.8 on discharge. Renal consultation was obtained and additional labs were sent. The patient was not felt to have evidence of lupus nephritis nor obstructive ureteropathy. The cause for the patient’s acute renal failure continues to be unclear; however, acute tubular necrosis and acute interstitial nephritis are believed to be most likely. The patient’s electrolytes stabilized, and she did not meet any indication for dialysis during her hospital course.
2. Anemia: The patient was noted to have a hematocrit of 29.2 on admission. Iron studies were obtained, which indicated that the patient was suffering from anemia of chronic disease secondary to her acute renal failure. She was started on erythropoietin supplementation. The patient was discharged with a hematocrit of 24.4 with close followup. The patient did not have any signs of active bleeding during her course, and hemolysis labs indicated that this was not a destructive process but rather a matter of red blood cells underproduction.
3. Hyperkalemia: The patient was noted to have a hyperkalemia of 6.6 upon admission. The patient was given insulin, glucose, Kayexalate, and calcium gluconate while in the emergency department, which brought her potassium to normal limits. The patient’s potassium was followed throughout her hospitalization and continued to be normal throughout her hospitalization after these measures that were taken in the emergency department.
4. Urinary tract infection: The patient was noted on admission to have a urinary tract infection with a urinalysis showing 2+ bacteria, 5 white blood cells and a urine culture revealing greater than 100,000 colony-forming unit of gram negative rods. She was treated with Levaquin at a renal dose.
5. Atrial fibrillation: The patient was continued on her home dose of Coumadin and her INR was monitored. Her INR was noted to be subtherapeutic at 1.8 on the day prior to discharge, and her dose of Coumadin was increased.
6. Lupus: The patient had received a diagnosis of lupus in her 40s. However, ANA, rheumatoid factor, and other rheumatologic labs drawn in the hospital have been negative, and thus, we feel like the patient does not have lupus and certainly does not have a lupus nephritis.
7. GERD: The patient was continued on her outpatient dose of omeprazole.
8. Hypertension: The patient’s propranolol was decreased because of her renal failure, and her blood pressure was well controlled.
9. Hypothyroidism: The patient was continued on her home dose of Synthroid.
10. Breast cancer: The patient continued to receive her home dose of Arimidex throughout her course.
11. Chronic pain: The patient’s gabapentin was held throughout her course in the hospital due to her renal failure.
12. Osteopenia: The patient’s Actonel was held while she was in the hospital secondary to her acute renal failure.
DISCHARGE PLAN:
1. The patient is to follow a renal diet after discharge.
2. The patient is to see Dr. John Doe in nephrology clinic on Thursday. She is to have lab work done on Saturday and Tuesday. These labs results will be sent to Dr. John Doe for review. Dr. Doe will manage the patient’s erythropoietin injections.
3. Several of the patient’s medications were decreased in dose or frequency to account for her decreased creatinine clearance and acute renal failure.
4. The patient is instructed to call her primary care physician if she has any increased fatigue, swelling, confusion or dizziness, chest pain or difficulty breathing.
DISCHARGE MEDICATIONS:
1. Coumadin 2 mg p.o. daily.
2. Levaquin 250 mg every other day for a total of 7 days.
3. Propranolol 20 mg p.o. b.i.d.
4. Gabapentin 100 mg p.o. t.i.d.
5. Arimidex 1 mg p.o. daily.
6. Omeprazole 20 mg daily.
7. Clonazepam 0.5 mg at bedtime p.r.n.
8. Synthroid 100 mcg p.o. daily.
9. Nasonex 50 mcg nasally daily.
10. Tylenol 500 mg q.8 hours p.r.n. pain.
11. The patient’s Celebrex and Actonel were discontinued. The patient’s vitamin supplements were discontinued.
