REFERRING PHYSICIAN: John Doe, MD

REASON FOR CONSULTATION: Hyponatremia.

HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old hypertensive and diabetic, who was hospitalized after syncope and fall. He stated that he was dizzy and felt that his blood sugar was probably low. He sustained a scalp laceration. Carotid Dopplers revealed less than 50% stenosis. Chest x-ray was negative. MRI of the brain in the remote past revealed prominence of the cisterna magna on both sides. Pituitary was atrophic, having the appearance of empty sella back then. Head CT following this recent fall was done, which revealed no bleed or fracture, just soft tissue injury.

In the last month or so, his glyburide was increased. He has been on Trileptal for about 6 years for seizures. He has a glass of alcohol a couple of times a month. For many years, he had 3 rum and cokes each evening but has not done this for some time. While he was on Avandia, he has not had any swelling. Additionally, he was on lisinopril. He denies any edema. He feels he empties his bladder fully. Sometimes, he gets up at night to void. His blood sugars have been well.

PAST MEDICAL HISTORY: Hypertension and diabetes.

ALLERGIES: NO KNOWN DRUG ALLERGIES.

HABITS: As above regarding alcohol. He does not smoke.

OUTPATIENT MEDICATIONS: Trileptal 600 mg 2 tablets b.i.d., glyburide 2.5 mg t.i.d., metformin 500 mg t.i.d., Lipitor 40 mg daily, Avandia 8 mg daily, lisinopril 10 mg daily, and low-dose Bayer Aspirin 81 mg daily.

SOCIAL HISTORY: Married.

FAMILY HISTORY: Denies family history of kidney disease, nephrolithiasis or electrolyte disorders.

REVIEW OF SYSTEMS: Denies pain, nausea, lightheadedness or thyroid problems. He has been eating well. He is frustrated regarding his diet. He denies cough, shortness of breath, chest pain, back pain, kidney problems, problems emptying his bladder, prostate problems, edema or rash.

PHYSICAL EXAMINATION:
VITAL SIGNS: Afebrile. Blood pressure 118/74, blood pressure last night on chart was 178/96. Today, pulse is 74, respirations 22, weight 110 pounds and stable. Output on first shift was charted as 1250 with 90 in.
GENERAL: Alert, appropriate, and talkative.
HEENT: Anicteric. The patient does have ecchymosis around his eyes and forehead.
NECK: Without JVD or adenopathy.
CHEST: Clear.
BACK: Without CVA tenderness.
HEART: Regular rate and rhythm without gallop or rub.
ABDOMEN: Soft.
EXTREMITIES: Without edema.

LABORATORY DATA: Urine osmolality is still pending. Spot urine sodium 64. TSH was within normal limits. Glucose 114, BUN 14, creatinine 0.8, sodium 123, potassium 5.1, chloride 89, bicarbonate 27, and anion gap 9. Calcium, phosphorus, and albumin within normal limits. Serum osmolality 258, a.m. cortisol 22.2, within normal limits.

IMPRESSION:
1. Hyponatremia.
2. Hyperkalemia.
3. Diabetes.
4. Hypertension.
5. Recent fall.
6. Obstructive sleep apnea.

PLAN: Unfortunately, the patient’s urine osmolality has not yet been done. His a.m. cortisol and TSH are within normal limits. I suspect either SIADH or polydipsia. He is euvolemic and the urine osmolality will help us sort out what is going on. For now, we will start with fluid restriction. I will defer to the attending but would consider stopping glyburide and managing diabetes with an alternative agent as this may cause hyponatremia. Trileptal may be contributing also, though he has been on that for a number of years. The glyburide dose was recently increased. Will defer to primary physician on this. The patient does have a history of significant alcohol use. Questionable underlying liver disease. Consider repeating the CT scan in light of his recent fall. He is also on ACE inhibitor, which could be contributing, but I think it is less likely. Will check the urinalysis, renal ultrasound and renal artery Doppler. Potentially, if he has difficulty with urinary retention, this may explain why he may have elevated potassium. In this diabetic, there is a potential for some underlying hyporeninemic hypoaldosteronism. I would also recommend checking orthostatics and following up blood pressures. Will defer diabetes management to primary service, as well as management of his recent fall. I recommend following up his blood pressures. I recommend the patient continue CPAP for his obstructive sleep apnea.

Thank you very much for this consultation. We will follow the patient with you.

HISTORY OF PRESENT ILLNESS: The patient was evaluated in the pediatric nephrology clinic for ongoing care of her history of multicystic dysplastic kidney, UTIs, and metabolic syndrome. This is a patient with Turner syndrome. Today, she is accompanied by her grandmother. The history was obtained from the patient and her grandmother.

The patient is a (XX)-year-old young lady with a diagnosis of Turner syndrome who was born with a right multicystic dysplastic kidney and a normal left kidney that has developed compensatory hypertrophy. She also has a history of urinary tract infections in the past but has had a negative VCUG.

In her adolescence, she developed obesity and metabolic syndrome with some insulin resistance and hyperlipidemia. She has also had some intermittent elevated high blood pressures. She has no history of structural cardiac disease. She has also had some urine microalbumin measurements that have been elevated, and we have been following her closely for early signs of hyperfiltration injury.

Today, she returns for her routine followup. She has been generally healthy since her last visit. She has had no significant intercurrent illnesses and has no complaints today. She still has not made any significant lifestyle modifications and has gained weight. She is not exercising and does not make the best food choices. She does complain of some back pain related to her scoliosis and is looking for a new orthopedic surgeon. She says she has some intermittent mild headaches that do not require any medications and self-resolves.

She is also having some irregular menstrual spotting due to starting new hormone replacement in the form of birth control pills. She otherwise is feeling well. She has had no chest pain, palpitations, lightheadedness, dizziness, dyspnea and no urinary symptoms.

In addition to what is mentioned above, all other systems reviewed were negative.

SOCIAL HISTORY: The patient lives at home with her grandmother. She does admit to being depressed intermittently because of her grandfather’s death and this makes her eat more.

MEDICATIONS: Oral contraceptive pill and vitamin D 2000 units daily.

PHYSICAL EXAMINATION: The patient’s height is 160 cm and weight is 94 kg, which is at the 98th percentile. Her blood pressure was initially 132/86; on repeat, 126/70. On examination, she is a well-appearing, obese, adolescent girl, in no distress. She does have short stature. She has no other obvious dysmorphic features. Oropharynx is clear. She has no tonsillar hypertrophy. Her TMs are clear. Her neck is supple. She has no cervical lymphadenopathy. Her chest is clear to auscultation bilaterally. Her heart has regular rate and rhythm. No murmurs, rubs or gallops. Her abdomen is soft, nontender, and nondistended. She has no hepatosplenomegaly. No joint swelling or tenderness. No pallor or rash. She has some striae on her abdomen and no peripheral edema. Her neuro exam is nonfocal.

LABORATORY DATA: The patient’s urine dipstick today has specific gravity greater than 1.030, pH of 5.6. There was large blood, 1+ protein and 1+ ketones; it was otherwise negative. A urine microalbumin to creatinine ratio was sent to the lab and is elevated at 68. In reviewing her previous ratios; in October, it was 60; in May, it was 110; and even back six years ago, it was slightly abnormal at 32.

Blood work was done today as well. Her serum creatinine concentration is normal at 0.64 mg/dL. Electrolyte panel including potassium of 4.2 and her serum glucose was 98, which was not fasting.

IMPRESSION: The patient is a (XX)-year-old young woman with Turner syndrome who was born with a right-sided multicystic dysplastic kidney with a normal left kidney that has demonstrated compensatory hypertrophy. She also has a history of UTIs, but none recently, and has had a negative VCUG in the past.

Currently, she is obese and has a metabolic syndrome with insulin resistance and hyperlipidemia. She has had some intermittent high blood pressures, and most concerning, she has now had sequential urine microalbumin to creatinine ratios that have been elevated in the microalbuminuria range, which is consistent with early hyperfiltration.

Given that the patient has a single kidney, she is at risk for this hyperfiltration area injury and chronic kidney disease, and certainly, her obesity and metabolic syndrome are significant risk factors for the progression of CKD.

RECOMMENDATIONS:
1.  Given that the patient has had sustained microalbuminuria over the last year, we do think she meets indications for ACE inhibitor therapy, particularly given the fact that she has decreased nephron mass from her single kidney. We have prescribed lisinopril 5 mg daily; this will also help with lowering her blood pressure. We have gone over how this medication is dosed and potential side effects, including cough, lightheadedness, and dizziness. We did not go over the risks for pregnancy given that it is our understanding that she has had an oophorectomy.
2.  We have again encouraged the patient to make therapeutic lifestyle modifications to optimize her weight. We emphasized the importance of weight loss and regular exercise in her cardiovascular and renal health. We warned her that her progression of chronic kidney disease will certainly be faster if she remains obese and she will be at greater risk of developing significant hypertension and requirement for more medication.
3.  We have asked the patient to call us if she has any trouble taking her medication on a daily basis. She is scheduled to have lab work done in one to two weeks in preparation for her endocrinology visit; therefore, we have given her a lab slip to have a repeat renal function panel to monitor her creatinine and potassium while taking an ACE inhibitor. We asked her to give the phlebotomist this requisition when she goes for her endocrine labs.
4.  We would like to evaluate the patient again in nephrology clinic in one month’s time to see how she is tolerating her medication and check her blood pressure and urinalysis.

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.

PREOPERATIVE DIAGNOSIS: Healthy kidney donor.

POSTOPERATIVE DIAGNOSIS: Healthy kidney donor.

OPERATION PERFORMED: Laparoscopic left donor nephrectomy.

SURGEON: John Doe, MD

ANESTHESIA: General endotracheal.

ESTIMATED BLOOD LOSS: Minimal.

COMPLICATIONS: None.

SPONGE AND NEEDLE COUNTS: Correct.

INDICATION FOR OPERATION: This is a healthy kidney donor. After undergoing the preoperative evaluation, the patient was found to have no contraindication to surgery. He was fully counseled on the risks and benefits of the procedure and agreed to proceed with the left-sided kidney donation.

DESCRIPTION OF OPERATION: After appropriate operative consent was obtained, the patient was taken to the operating room, and general endotracheal anesthesia was induced without any hemodynamic compromise or complication. At this point in time, the patient was put into a right decubitus position with padding at all pressure points with the bed in full flexion. The abdomen and left flank were prepped and draped in sterile fashion using DuraPrep.

We placed a 12 mm port in the left upper quadrant. This was approximately 7 cm below the costal margin. This was done using an open technique and in the midclavicular line. Great care was taken to avoid injury to any hollow viscus structures upon insertion of this port. At this point, pneumoperitoneum was carried out using CO2 insufflation of 15 mmHg. A second 10 mm port was carefully placed approximately 10 cm below this. This was again done under direct visualization. A 5 mm port was carefully placed in the left upper quadrant in the midaxillary line, again under direct visualization.

At this point in time, we began with full mobilization of the left colon. This was done using sharp and blunt technique using a Harmonic scalpel and the colon was brought over to the midline. This allowed access to the kidney. The hilar structures were carefully identified, and the renal vein was carefully identified and dissected free of surrounding tissue to pass the aorta. The adrenal vein was carefully identified, doubly clipped and divided. In a similar fashion, the gonadal vein was carefully identified, doubly clipped and divided as well. At this point in time, the renal artery was carefully identified and circumferentially dissected free of surrounding tissue. It was noted to be a single artery. The upper pole was then carefully dissected from surrounding tissue using the Harmonic scalpel. The renal vein was carefully preserved.

The lateral attachments of the kidney were carefully taken down using the Harmonic scalpel and the kidney was brought over medially. The lateral sides of the artery and vein were carefully dissected free of surrounding tissue. There was noted to be a large lumbar vessel directly coming off the renal vein. This was doubly clipped and divided. Next, the ureter complex along with its vascular supply was carefully dissected free of surrounding tissue with great care being taken to avoid injury to the vascular supply of the ureter with the iliac vessels.

It should be noted that at this point in time a separate incision was carefully made in the left lower quadrant. This incision was taken carefully down through fascial layers using electrocautery, and a hand port was carefully put into position. The patient was given additional fluid as well as diuretics. The pneumoperitoneum was released for approximately 25 minutes. At that time, we proceeded with recreating a pneumoperitoneum. The arteries were then carefully stapled using a vascular staple load followed by the renal vein. The kidney was carefully removed from the hand port site and placed on ice. The ureter was carefully divided to the level of the iliac vessels. and the kidney was then removed from the field as specimen for transplantation. The remaining portion of the ureter was carefully ligated using a 0 silk tie.

The peritoneal cavity was carefully examined again. There was no immediate evidence of any bleeding as hemostasis had been maintained. The peritoneal cavity was carefully irrigated and the irrigant aspirated. The pneumoperitoneum was then carefully removed and then all ports were carefully removed. Both donor fascial sites were carefully reapproximated using 0 Vicryl figure-of-eight stitch. The hand port incision was carefully reapproximated in two layers of running #1 PDS suture. All wounds were carefully irrigated and a Marcaine pain pump was carefully put into position, and the skin of all incisions was carefully approximated using a 4-0 Monocryl running subcuticular stitch. Appropriate sterile dressings were applied. The patient tolerated the procedure well with normal vital signs throughout the entirety of the case. The patient was extubated in the operating room and taken to postop recovery in stable condition.

PREOPERATIVE DIAGNOSIS:  End-stage renal disease, recurrent infection, right kidney.

POSTOPERATIVE DIAGNOSIS:  End-stage renal disease, recurrent infection, right kidney.

OPERATION PERFORMED:
1.  Laparoscopic exploration.
2.  Right-sided laparoscopic nephrectomy.

SURGEON:  John Doe, MD

ASSISTANT:  Jane Doe, MD

ESTIMATED BLOOD LOSS:  Less than 100 mL.

COMPLICATIONS:  None.

SPONGE AND NEEDLE COUNT:  Correct.

INDICATIONS FOR OPERATION:  This is an adult male with a history of end-stage renal disease requiring hemodialysis. The patient presents today for elective right-sided nephrectomy secondary to recurrent infections and possibility of future live donor transplantation.

DESCRIPTION OF OPERATION:  After a lengthy discussion of the risks, benefits and procedures, the patient was taken to the operating room and appropriate endotracheal anesthesia was induced without any comments or complications. The patient was put into a left decubitus position, and the right abdomen was prepped appropriately in a sterile fashion using DuraPrep. At this point in time, the patient had two right upper quadrant ports placed using an open technique in the midclavicular and midaxillary line. A third 5 mm port was carefully placed in the right upper quadrant under direct visualization.

At this point in time, pneumoperitoneum was created using CO2 insufflation to 15 mmHg. Upon completion of this and extensive exploration of the peritoneal cavity, there were no abnormalities. The right kidney was noted to have a large amount of inflammatory response around it and was adhesed to the lateral sidewall as well as the adrenal gland. A hand port was carefully put into position. This was measured to be approximately 7 cm, and the incision was carried down through the fascial layers using electrocautery. The retractor was put into position.

From this point, we began by first mobilizing the lateral attachments of the right kidney. Upon completion of the ureter, the pedicle was carefully identified, and a Harmonic scalpel was used to carefully circumferentially dissect around this. The ureter as well as vessels was carefully divided using a vascular stapler load. The kidney was then carefully mobilized using the Harmonic scalpel, first at the level of the upper pole, and the adrenal gland was carefully dissected off the upper pole of the kidney without any complications. The lateral attachments were carefully taken down.

At this point in time, the duodenum was carefully tracked in a medial fashion with care being taken to avoid injury to the duodenum itself. The vena cava was thus identified, as was the right renal vein. The right renal artery was also carefully identified. At this point in time, the kidney was fully mobilized, except for its vascular pedicle. The vascular pedicle was then carefully identified using a laparoscopic vascular stapler and then removed from the hand port. Repeat inspection failed to reveal evidence of any other abnormalities, and there was noted to be excellent hemostasis. There was no evidence of hollow viscus injury.

All ports were then carefully removed. The fascia at the 12 mm port was carefully reapproximated using 0 Vicryl figure-of-eight stitch. The hand port site was carefully closed in two layers of 0 PDS running suture. The skin incisions were carefully reapproximated using 4-0 Monocryl in a running subcuticular stitch. Appropriate sterile dressings were applied. The patient tolerated the procedure well with no complications during the case. The patient was extubated in the operating room and taken to the postoperative recovery in stable condition.

PREOPERATIVE DIAGNOSIS: Renal failure with developing hematoma in the left arm, now needing access for hemodialysis.

POSTOPERATIVE DIAGNOSIS: Renal failure with developing hematoma in the left arm, now needing access for hemodialysis.

OPERATION PERFORMED: Right internal jugular Permacath placement.

SURGEON: John Doe, MD

ANESTHESIA: IV sedation.

COMPLICATIONS: None.

EBL: Minimal

CONDITION: Stable.

FINDINGS: There is a very laterally positioned internal jugular vein.

DESCRIPTION OF PROCEDURE: After informed consent was obtained, the patient was taken to the OR and prepped and draped in a sterile fashion. The right IJ was identified with ultrasound; again, appeared to be very, very lateral. This was accessed with a large bore needle and a wire was inserted and manipulated the SVC-right atrial junction. Next, the tract was then sterilely dilated. Finally, the introducer sheath was advanced over the wire under fluoroscopic guidance. The catheter tip was in position in the right atrium. The catheter was then brought through a retrograde and subcutaneous tunnel through the right chest. The catheter was then fully assembled. Each of the two lumen were aspirated with good blood return and flushed with heparinized saline solution. The catheter was secured in place with 3-0 nylon. The incision was approximated with 4-0 Vicryl stitches. Sterile dressing was applied. The patient was returned to recovery in stable condition.

DATE OF PROCEDURE: MM/DD/YYYY

PREOPERATIVE DIAGNOSIS: Renal failure.

POSTOPERATIVE DIAGNOSIS: Renal failure.

OPERATION PERFORMED: Insertion right internal jugular Permacath.

SURGEON: John Doe, MD

DESCRIPTION OF PROCEDURE: The patient was prepped with Betadine and draped with routine sterile drapes. A right internal jugular venipuncture was done without difficulty. Guidewire was advanced into the right atrium under C-arm guidance. Tunnel was then developed, and the dilator and sheath were then passed. Dilator wire was removed. The catheter was advanced to the atrium and the sheath was removed. Hemostasis was obtained. The catheter was aspirated and filled with saline and heparin. The catheter was sutured in place with 3-0 nylon, and the neck wound was closed with 3-0 nylon. Dressings were applied. The patient tolerated the procedure well with approximately 5 cc of blood loss. Sponge, needle, and instrument counts were correct. The patient was sent to the recovery area in excellent condition.

DATE OF PROCEDURE: MM/DD/YYYY

PREOPERATIVE DIAGNOSIS: Renal failure, need for dialysis access.

POSTOPERATIVE DIAGNOSIS: Renal failure, need for dialysis access.

OPERATION PERFORMED: Left subclavian Permacath placement.

ASSISTANT: None.

ANESTHESIA: IV sedation with 18 mL of 0.5% Xylocaine with epinephrine for local analgesia.

DESCRIPTION OF PROCEDURE: The patient was brought to the operating room and placed in a supine position whereupon a blood pressure cuff, EKG leads, and O2 monitor were placed. After administrating adequate IV sedation, the patient was prepped and draped in a sterile fashion. The patient received preoperative antibiotics and had sequential compression devices on. The patient had a total of 18 mL 0.5% Xylocaine with epinephrine for local analgesia in the left subclavicular area. Using Seldinger technique, the subclavian vein was entered, and the superior vena cava was cannulated with a guidewire. This was confirmed with fluoroscopy. A separate stab wound was made inferior and lateral to the insertion site and a tunnel was created. The 23 cm dialysis catheter was tunneled through this area and then advanced into the superior vena cava via guidewire sheath apparatus. Both insertion site and secondary incision site were closed with subcuticular 4-0 Vicryl in an interrupted fashion. Sterile dressing was applied. The Quinton Permacath had excellent blood return. Both ports were flushed with half saline solution. The patient was taken to the postanesthesia care in stable condition. There were no immediate complications, and x-ray will be obtained.

NOTE: PermCath is the preferred and correct word, though Permacath can also be found in reference sources. Go with PermCath if no specific request for “Permacath” is made by the doctor.

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.