Case Study 8 Consult
CONSULTATION
PATIENT NAME: Chapman Robert Kinsey
PATIENT ID: 110589 DOB: 04/07/---- AGE: 87 Sex: M
ROOM NO.: 322-B
CONSULTANT: Trevor Jordan, MD, Nephrology
REQUESTING PHYSICIAN: Martha C. Eaton, MD, Geriatrics
DATE OF CONSULT: 02/24/----
REASON FOR CONSULT: Acute on chronic renal failure. Patient is an 87 year old Caucasian male who has a history of hypertension, severe peripheral vascular disease, chronic renal insufficiency, and atrial fibrillation. He was admitted yesterday for treatment of an infected toe. The plan was to obtain an angiogram to check patients’ blood flow; however he was discovered on admission labs to have acute on chronic renal failure, patient states he is unaware of kidney problems before. He states he is able to pass his urine without difficulty, no obstructive symptoms, no history of kidney stones, no urinary tract infections, no hematosis, no dysuria, and no diabetes mellitus. Patient states he has a history of hypertension, but it has been very mild. He has had trouble with vascular disease to both legs.
Patients’ base line serum creatinine is 1.5 to 1.7, patients laboratory studies from this morning indicates a BUN of 101 and a creatinine of 3.9.
ALLERGIES: Penicillin which causes anaphylactic shock.
CURRENT MEDICATIONS: Lanoxin, furosemide, Zocor, Prinivil, diltiazem, pentoxifyline, and as needed pain medications.
PAST HISTORY: Significant for hypertension, severe peripheral vascular disease, chronic atrial fibrillation, on Coumadin. History of the left carotid endarterectomy, history of CHF, status post cataract surgery and amputation of the right great toe.
SOCIAL HISTORY: Past history of both tobacco abuse and alcohol abuse.
FAMILY HISTORY: Never before any kidney disease. Brother has diabetes mellitus.
(Continued)
CONSULTATION
PATIENT NAME: Chapman Robert Kinsey
PATIENT ID: 110589
DATE OF CONSULT: 02/24/----
Page 2
REVIEW OF SYSTEMS:
PATIENT NAME: Chapman Robert Kinsey
PATIENT ID: 110589 DOB: 04/07/---- AGE: 87 Sex: M
ROOM NO.: 322-B
CONSULTANT: Trevor Jordan, MD, Nephrology
REQUESTING PHYSICIAN: Martha C. Eaton, MD, Geriatrics
DATE OF CONSULT: 02/24/----
REASON FOR CONSULT: Acute on chronic renal failure. Patient is an 87 year old Caucasian male who has a history of hypertension, severe peripheral vascular disease, chronic renal insufficiency, and atrial fibrillation. He was admitted yesterday for treatment of an infected toe. The plan was to obtain an angiogram to check patients’ blood flow; however he was discovered on admission labs to have acute on chronic renal failure, patient states he is unaware of kidney problems before. He states he is able to pass his urine without difficulty, no obstructive symptoms, no history of kidney stones, no urinary tract infections, no hematosis, no dysuria, and no diabetes mellitus. Patient states he has a history of hypertension, but it has been very mild. He has had trouble with vascular disease to both legs.
Patients’ base line serum creatinine is 1.5 to 1.7, patients laboratory studies from this morning indicates a BUN of 101 and a creatinine of 3.9.
ALLERGIES: Penicillin which causes anaphylactic shock.
CURRENT MEDICATIONS: Lanoxin, furosemide, Zocor, Prinivil, diltiazem, pentoxifyline, and as needed pain medications.
PAST HISTORY: Significant for hypertension, severe peripheral vascular disease, chronic atrial fibrillation, on Coumadin. History of the left carotid endarterectomy, history of CHF, status post cataract surgery and amputation of the right great toe.
SOCIAL HISTORY: Past history of both tobacco abuse and alcohol abuse.
FAMILY HISTORY: Never before any kidney disease. Brother has diabetes mellitus.
(Continued)
CONSULTATION
PATIENT NAME: Chapman Robert Kinsey
PATIENT ID: 110589
DATE OF CONSULT: 02/24/----
Page 2
REVIEW OF SYSTEMS: