DATE OF ADMISSION: MM/DD/YYYY
REASON FOR ADMISSION: Fluid overload, confusion.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old Asian gentleman with history of type 1 diabetes for many years, end-stage renal disease, on hemodialysis, who was recently admitted for hemodialysis catheter infection. The patient had removal of the infected catheter and revision of AV fistula during his last hospitalization. He literally went home two days prior to this admission. The patient was found to be somewhat more confused than usual by his wife. The patient was also complaining of some dyspnea on exertion, and the wife called paramedics for evaluation.
In the emergency room, the patient was found with some fluid overload on chest x-ray and his BNP came back elevated at 3240. The patient reports that dialysis has not been able to remove much fluid lately because of low blood pressure, and he thinks this is the reason for fluid retention. The patient, however, denies having any chest pain. His EKG showed atrial flutter with 4:1 AV conduction but no acute ST changes.
We also had a conversation with the patient’s wife who has been concerned about gradual progression of his confusion. He was seen by Dr. John Doe in the past, and he was told that he might have dementia. The patient’s wife is quite concerned about his gradual deterioration of mental status; cognition was clearer.
In terms of diabetes, he has been requiring very small dose of insulin, most likely due to renal failure. He only uses NPH, 6 in the morning, plus 1 unit of regular insulin before breakfast and 2 units of regular at dinner. The patient denies any significant hypoglycemia.
PAST MEDICAL HISTORY: Type 1 diabetes; end-stage renal disease, on hemodialysis; history of CHF; cardiac arrhythmia for which he has been followed by Dr. Jane Doe; and dementia.
ALLERGIES: See chart.
MEDICATIONS: Tums 2 tablets 3 times a day, Colace 100 mg b.i.d., Plavix 75 mg a day, colchicine 0.6 mg every Friday, aspirin 81 mg every other day, Nephro-Vite 1 capsule p.o. daily, Lopressor 75 mg b.i.d., Imdur 60 mg p.o. daily, enalapril 20 mg twice a day, NPH and Humalog as above, and Cardizem 120 mg q.a.m.
SOCIAL HISTORY: The patient does not smoke or drink.
PHYSICAL EXAMINATION:
GENERAL: The patient is a well-nourished and pleasant gentleman, in no acute distress. The patient is oriented x 3.
VITAL SIGNS: Temperature 101.2, blood pressure 120/62, and pulse rate between 60 to 70.
HEENT: Extraocular muscles are intact. Conjunctivae are clear. There is no proptosis.
NECK: Thyroid normal without any obvious goiter or nodularities. There is no lymphadenopathy.
LUNGS: Clear without any obvious wheezing but minimal crackles at the bases.
HEART: Regular rhythm and rate, no S1 and S2.
ABDOMEN: Bowel sounds are present, nontender, nondistended.
EXTREMITIES: There is no edema, no diabetic ulceration.
LABORATORY DATA: BUN 54, creatinine 7.2, sodium 138, potassium 4.8, chloride 99, bicarbonate 27, calcium 8.6, protein 4.8. Liver function tests within normal limits. CBC shows WBC of 10.2, hematocrit of 32.8, and platelet count 276. BNP of 3240.
DIAGNOSTIC DATA: Chest x-ray shows mild congestion. CT of the head, which was done in ER, showed periventricular white matter but no change since previous.
IMPRESSION AND PLAN:
1. Fluid overload: The patient was admitted with fluid overload. There has been some problem with dialysis in that not enough fluid has been taken off due to low blood pressure. We will call nephrology service for dialysis as well as cardiology service for possible congestive heart failure.
2. Possible dementia.
3. Type 1 diabetes: The patient does not require much insulin due to his renal failure. We will continue with usual home dose of insulin, and we will make any necessary adjustments in the hospital.
