DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: Acute renal failure.
HISTORY OF PRESENT ILLNESS: We were kindly asked to evaluate this (XX)-year-old male who was brought to the emergency department by EMS when he was found unresponsive at his home and was in cardiac arrest with ventricular fibrillation. The patient was successfully resuscitated and was then admitted to the ICU. Currently, the patient is on mechanical ventilation and is sedated. His morning lab work shows elevated BUN and creatinine, and renal consult is now requested. The patient is unable to give any history and most of the history was obtained from the patient’s spouse at the bedside. She states that the patient has history of hypertension, hypercholesterolemia, and coronary artery disease but has no previous history of kidney disease or kidney stones. The patient was in his usual health until last night when he went into cardiac arrest.
PAST MEDICAL HISTORY: As per history of present illness.
PAST SURGICAL HISTORY: Status post CABG.
FAMILY HISTORY: Noncontributory.
SOCIAL HISTORY: The patient is married. No history of alcohol or illicit drug use.
ALLERGIES: No known drug allergies.
HOME MEDICATIONS: Metformin, which was stopped two weeks ago, aspirin, Crestor, Tricor, multivitamin, metoprolol, enalapril, and fish oil.
CURRENT MEDICATIONS: Zosyn, IV fluids with half normal saline, amiodarone, and propofol infusion.
REVIEW OF SYSTEMS: Unobtainable.
PHYSICAL EXAMINATION:
GENERAL: The patient is a middle-aged obese male, who is currently sedated, on mechanical ventilation.
VITAL SIGNS: Temperature afebrile; blood pressure 138/68; pulse rate 86, the patient appears in sinus rhythm on monitor; and respiratory rate 14.
HEENT: Normocephalic and atraumatic. Orally intubated.
NECK: Supple. Midline trachea.
LUNGS: Good air movement bilaterally. No wheezing or crackles.
HEART: Regular, S1 and S2.
ABDOMEN: Soft. Bowel sounds positive, hypoactive. No visceromegaly.
EXTREMITIES: No edema.
NEUROLOGIC: Sedated.
LABORATORY DATA: WBC 13.6, hemoglobin 13.6 with hematocrit of 40.2, and normal platelet count. Chemistry showed sodium 138, potassium 3.6, bicarb 19, BUN and creatinine of 34 and 2.3 respectively, which is increased from 22 and 1.8 yesterday, calcium 7.9, total protein 6.4 with albumin of 4.2. CK was 292. Troponin is 2.5, which is increased from yesterday of 0.04. Alcohol level was negative as well as acetaminophen level, and the drug screen was negative. Initial blood gases showed pH of 7.18, pCO2 of 60, and pO2 of 178.
DIAGNOSTIC STUDIES: Chest x-ray showed cardiomegaly and bilateral infiltrate. CT of the brain was unremarkable.
IMPRESSION AND PLAN:
1. Acute renal failure, nonoliguric, probably due to hemodynamic instability. Also need to rule out rhabdomyolysis; although, the patient’s total CPK is not very high. We will send urine electrolytes, osmolality, and also we will recommend avoiding any potential nephrotoxic agents. We will continue with the IV fluids and monitor urine output and BMP.
2. Status post cardiac arrest secondary to ventricular fibrillation. Cardiology is following the patient. The patient is on amiodarone drip and is now in sinus rhythm.
3. Ventilator-dependent respiratory failure. Further management by Critical Care service.
4. Metabolic acidosis, probably due to lactic acidosis and renal failure. We will change IV fluids with sodium bicarbonate in it, and we will follow up with the BMP.
5. Acute myocardial infarction. Further management by Cardiology service.
6. Hypertension. The patient’s blood pressure is fairly well controlled currently. We will avoid using ACE inhibitors at this time until his renal function improves.
