DATE OF ADMISSION: MM/DD/YYYY
DATE OF DISCHARGE: MM/DD/YYYY
FINAL DIAGNOSES:
1. Renal failure.
2. Atrial fibrillation.
3. Dehydration.
4. Pneumonia.
HOSPITAL COURSE: This (XX)-year-old had presented to the emergency department with history of nausea, vomiting, and coffee-ground emesis. He was also noted to have rapid atrial fibrillation in the ED. He was initially admitted as it was felt that the patient did not have a primary care physician. Subsequently, he turned out to be registered with a local primary care. He was also noted to have renal insufficiency with BUN of 39 and creatinine of 3.7. His initial sodium was 150, and his white count was 21. Renal ultrasound was obtained.
The patient was seen by Cardiology in view of his rapid atrial fibrillation; they agreed with serial cardiac enzymes and also started the patient on a Cardizem drip and ordered an echo and IV fluids. The patient was also seen by Nephrology in view of the renal insufficiency, and they thought that this was probably acute secondary to decompensated CHF and also secondary to diabetes and hypertension. They discontinued Bumex drip and advised consideration of Zaroxolyn and wanted to monitor the electrolytes and renal function closely. They also ordered a 24-hour urine collection for creatinine clearance and total protein. The patient was also seen by Pulmonary for lung infiltrate.
A consult was also requested from Infectious Disease, and they felt that the increased leukocytosis might be related to the CDT related colitis but also felt that this might be related to the coagulase-negative staphylococcus. Also considered the possibility of leukocytosis secondary to myeloproliferative disorder, but felt strongly that this was all secondary to infection. They started the patient on IV vancomycin and also initiated oral Flagyl and ordered CDT study.
Initial chest x-ray had shown right lower lobe infiltrate with small pleural effusion. Initial chemistry showed potassium of 3.3 and sodium of 150, BUN 39, creatinine 3.7, and a blood sugar of 375. This was rapidly corrected. However, the renal insufficiency persisted generally with BUN of about 40 and creatinine of about 3.8 to 4.5. Initial CBC was 21 with hemoglobin of 14.2, and this was monitored closely, and the white count actually went up to 37 the next day. Endocarditis was ruled out. Over the next few days, the white count slowly came down and eventually it was down to 14.6 with hemoglobin of 10.4.
The patient was monitored closely and was followed by the different consultants. Blood pressure was controlled. Potassium was replaced, and a consult was put in for possible dialysis. The patient’s family wanted him to have dialysis, but the patient himself was not sure if that is what he wanted. A swallow study was done. The patient’s general condition remained fairly poor. A lower extremity venous Doppler was negative for DVT. Nephrology wanted to do dialysis if the family agreed, and at that point, they were considering transfer. A family meeting was arranged, but apparently, they did not show up. The patient was subsequently transferred with the intent of dialysis though the patient at this point was a DNR. Again, at this point, it appeared that the patient did not want the dialysis, but the family was insisting on it.
A consult was obtained from the palliative care team. At this point, his BUN was 76 and creatinine was 6.8, hemoglobin 10.8, and potassium was 3.5. Nephrology continued to follow the patient. Detox consult was also placed. At this point, since the family had insisted on dialysis, a consult was placed to put in the dialysis access, but the patient continued to refuse dialysis and said that he just wanted to go home. His general condition continued to remain fairly poor. He told us that he did not want dialysis, that he wanted to go home, and he was also aware that his family wanted him to have the treatment. A psych consult was obtained at this point to see how valid the patient’s own opinion was, as regards his general condition, and the psychiatrist confirmed that the patient was competent to make his own decision.
The patient continued to refuse dialysis and also did not want the dialysis port placed. After numerous discussions between hospice, case management, Palliative Care, and us, it was felt that the patient should be discharged to home with hospice and that his wishes should be granted, as regards him not wanting any further invasive treatments, including dialysis. He was therefore discharged to home.
