Sample Type / Medical Specialty: Consult - History and Phy.
Sample Name: Azotemia Consult
Description: Acute renal failure, probable renal vein thrombosis, hypercoagulable state, and deep venous thromboses with pulmonary embolism.
(Medical Transcription Sample Report)
REASON FOR CONSULTATION: Azotemia.
HISTORY OF PRESENT ILLNESS: The patient is a 36-year-old gentleman admitted to the hospital because he passed out at home.
Over the past week, he has been noticing increasing shortness of breath. He also started having some abdominal pain; however, he continued about his regular activity until the other day when he passed out at home. His wife called paramedics and he was brought to the emergency room.
The patient has had a workup at this time which shows bilateral pulmonary infarcts. He has been started on heparin and we are asked to see him because of increasing BUN and creatinine.
The patient has no past history of any renal problems. He feels that he has been in good health until this current episode. His appetite has been good. He denies swelling in his feet or ankles. He denies chest pain. He denies any problems with bowel habits. He denies any unexplained weight loss. He denies any recent change in bowel habits or recent change in urinary habits.
GENERAL: A gentleman seen who appears his stated age.
VITAL SIGNS: Blood pressure is 130/70.
CHEST: Chest expands equally bilaterally. Breath sounds are heard bilaterally.
HEART: Had a regular rhythm, no gallops or rubs.
ABDOMEN: Obese. There is no organomegaly. There are no bruits. There is no peripheral edema. He has good pulse in all 4 extremities. He has good muscle mass.
LABORATORY DATA: The patient's current chemistries include a hemoglobin of 14.8, white count of 16.3, his sodium 133, potassium 5.1, chloride 104, CO2 of 19, a BUN of 26, and a creatinine of 3.5. On admission to the hospital, his creatinine on 6/27/2009 was 0.9.
The patient has had several studies including a CAT scan of his abdomen, which shows poor perfusion to his right kidney.
1. Acute renal failure, probable renal vein thrombosis.
2. Hypercoagulable state.
3. Deep venous thromboses with pulmonary embolism.
DISCUSSION: We are presented with a 36-year-old gentleman who has been in good health until this current event. He most likely has a hypercoagulable state and has bilateral pulmonary emboli. Most likely, the patient has also had emboli to his renal veins and it is causing renal vein thrombosis.
Interestingly, the urine protein was obtained which is not that elevated and I would suspect that it would have been higher. Unfortunately, the patient has been exposed to IV dye and my anxiety is that this too is contributing to his current problem.
The patient's urine output is about 30 to 40 mL per hour.
Several chemistries have been ordered. A triple renal scan has been ordered.
I reviewed all of this with the patient and his wife. Hopefully under his current anticoagulation, there will be some resolution of his renal vein thrombosis. If not and his renal failure progresses, we are looking at dialytic intervention. Both he and his wife were aware of this.
Thank you very much for asking to see this acutely ill gentleman in consultation with you.
Keywords: consult - history and phy., urine output, deep venous thromboses, renal failure, pulmonary embolism, renal, azotemia, hypercoagulable, vein, thrombosis, pulmonary,