***ATTENTION***MEDICARE HAS ELIMINATED CONSULTS as of Janurary 1, 2010. Click HERE to watch a 3-minute video about coding for "consults" in the hospital setting....
HPI: Patient followed in the past by my associate, Dr. Cho, for CKD with baseline
creatinine of 1.8 two weeks ago. Found to have severe ARF this morning associated with acidosis and
moderate hyperkalemia after presenting to the ER with “dehydration.” Renal service is
consulted for advice and opinion regarding treatment of this problem. The patient is currently
admitted under observation status to the hospitalist service.
ROS: Cardiovascular: Negative for CP/PND. GI: Negative for nausea, positive for diarrhea.
GU: Negative for obstructive symptoms or documented exposure to nephrotoxins.
All other systems reviewed and are negative.
PFSH: Remarkable for longstanding diabetes and HTN, negative family history of hereditary
renal disease and negative history of tobacco or ETOH abuse.
EXAM: CONSTITUTIONAL: 99/52, 18, 102. NAD; conversant. EYES: anicteric
sclerae, no proptosis, PERRL. ENMT: Normal aside from somewhat dry mucus membranes.
CARDIOVASCULAR: RRR, no MRGs, no edema. RESPIRATORY: Lungs
CTA, normal respiratory effort. GI: NABS, no HSM. SKIN: Warm and dry, decreased
turgor. PSYCHIATRIC: A&OX3 with appropriate affect.
Labs: BUN 99, creatinine 3.6, HCO3 14, K 5.9.
IMPRESSION
1. New, acute renal failure, most likely due to volume depletion due to diarrhea
2. History of underlying stage III CKD
3. Mild hypotension
PLAN
1. Bolus with another liter of NS wide open.
2. Then start D5W with 3 amps of HCO3 at 150 cc/hr.
3. Repeat labs in eight hours.
4. Further diagnostic testing will ordered if no improvement with volume repletion.
