PREOPERATIVE DIAGNOSIS: Right testicular tumor.

POSTOPERATIVE DIAGNOSIS: Right testicular tumor.

OPERATION PERFORMED: Right radical orchiectomy.

SURGEON: John Doe, MD

ANESTHESIA: General anesthesia via LMA.

COMPLICATIONS: None.

DRAINS: None.

ESTIMATED BLOOD LOSS: 5 mL.

INDICATIONS FOR OPERATION: This patient presents to the office with a six-month history of a rock-hard nodule in his right testicle. Tumor markers are unremarkable. We have recommended a right radical orchiectomy. Informed consent has been obtained.

DESCRIPTION OF OPERATION: The patient was placed on the operating table in the supine position. General anesthesia was administered via LMA. The right inguinal and scrotal areas were sterilely prepped and draped in the usual fashion.

A small inguinal incision was made and carried down through the subcutaneous fat to expose the external rectus fascia. This was opened along the length of its fibers to expose the genital branch of the nerve as well as the spermatic cord. The nerve was carefully dissected and retracted medially to preserve it. The spermatic cord was lassoed with a Penrose drain, which was then looped and tightened as a tourniquet.

Further dissection of the spermatic cord distally freed the testicle. The gubernaculum was sharply incised with electrocautery. Hemostasis was obtained throughout the procedure when needed with electrocautery and silk ties. When the testicle had been delivered, the proximal cord was dissected to the internal inguinal ring. The cord was then divided between three sets of clamps. The testicle was removed. The proximal spermatic cord was then tied with 0 silk free ties. A total of two ties were placed on each of the two vascular pedicles and one 0 silk tie was placed on the vas deferens. The proximal cord was then examined for hemostasis, and there was no active bleeding. One of the ties on the proximal cord was left fairly long for possible future use during a retroperitoneal node dissection.

The floor of the inguinal canal was then examined for hemostasis, and there was no active bleeding. The nerve had been preserved. The rectus fascia was then reapproximated using interrupted 2-0 silk sutures. The wound was then irrigated with sterile water. The subcutaneous tissue was reapproximated with a running 3-0 chromic. The skin was closed with staples followed by sterile dressings and Tegaderm. The patient tolerated the procedure well and was returned to the recovery room in satisfactory condition. Sponge and needle counts were correct x2.

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PREOPERATIVE DIAGNOSIS: Left epididymal mass.

POSTOPERATIVE DIAGNOSIS: Left epididymal mass.

PROCEDURE PERFORMED: Left scrotal aspiration via an inguinal approach and excision of left epididymal mass.

SURGEON: John Doe, MD

ASSISTANT: Jane Doe, MD

ANESTHESIA: General.

SPECIMENS: Include the left epididymal mass.

COMPLICATIONS: None.

INDICATIONS: Refer to the preoperative history and physical.

DESCRIPTION OF PROCEDURE: The patient received clindamycin 800 mg IV piggyback on call to the operating room. The patient was brought to day surgery, to the main operating room. He was placed in the supine position. After adequate instillation of general anesthesia, the left inguinal area and scrotum were clipped preoperatively. He was prepped and draped in the usual sterile fashion.

A left inguinal incision was established and extended to the subcuticular tissue on Scarpa’s fascia with blunt and sharp dissection. The external oblique fascia was opened in the direction of its fibers from the internal and external ring. The left spermatic cord was encircled with a small Penrose drain. The left testis was delivered from the left hemiscrotum. The left testis was normal. About the tail of the left epididymis was an approximately 10 mm firm epididymal mass. The mass was bluntly and sharply excised and sent to the department of pathology for frozen and permanent section. Frozen section revealed a probable granuloma.

The left testis and epididymis were vigorously irrigated. Hemostasis was obtained. The left testis was returned to the left hemiscrotum. The patient tolerated the procedure well. The estimated blood loss was negligible. The patient received approximately 300 mL of IV fluid. The procedure was performed without transfusion. The procedure was performed without complication.

PLAN: The plan for this patient includes routine postoperative care. The patient will be seen in the office in one to two weeks for postoperative evaluation. The disposition of this patient depends on his clinical course.

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DATE OF CONSULTATION: MM/DD/YYYY

REFERRING PHYSICIAN: John Doe, MD

CHIEF COMPLAINT: Left testicular torsion.

HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old Hispanic male who complains of sudden onset of left testicular pain. The pain progressively worsened and became less intermittent. The patient was brought to the emergency department by his parents.

The patient subsequently underwent a scrotal ultrasound, which initially revealed no flow to the left testicle and subsequently revealed some flow. The patient denies any trauma to the area. The patient denies any difficulty urinating.

PAST MEDICAL HISTORY: The patient’s past medical history is really unremarkable.

MEDICATIONS: None.

ALLERGIES: No known drug allergies.

PHYSICAL EXAMINATION:
GENERAL: The patient is alert and oriented, obviously somewhat uncomfortable.
VITAL SIGNS: He is afebrile. Temperature 97.8, pulse 76, blood pressure 128/68.
HEENT: Head is normocephalic. Eyes nonicteric.
ABDOMEN: Benign. There is no hernia.
GENITALIA: Normal-appearing external genitalia with an uncircumcised phallus without lesions or discharge. Scrotum is normally developed without lesions or slight fullness to the left hemiscrotum. The testicle itself is somewhat high-riding, much firmer and twice the size of the right testicle. The epididymis itself is extremely tender and indurated. However, the patient does state that the pain is actually improving. There is no significant cremasteric reflex on the left side.
EXTREMITIES: Without clubbing, cyanosis or edema.
NEUROLOGIC: The patient appears grossly intact.

LABORATORY DATA: The patient’s laboratory data revealed a hemoglobin of 15.4, hematocrit 45.2, and white blood cell count of 7.2.

ASSESSMENT: The patient has an acute torsion of the left testicle.

PLAN: At this point in time, the plan is to take the patient emergently to the operating room for left scrotal exploration, possible left orchiectomy, and possible left orchiopexy.

The procedure was discussed with both the patient and his parents in detail, who appeared to understand and agreed to proceed. The patient will be brought to the operating room emergently.

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PREOPERATIVE DIAGNOSIS: Recurrent right inguinal hernia.

POSTOPERATIVE DIAGNOSES: Undescended right testicle, chronic and recurrent right inguinal hernia.

OPERATION PERFORMED:
1. Right inguinal exploration, open technique.
2. Right orchiectomy.
3. Mesh repair, recurrent right inguinal hernia.

SURGEON: John Doe, MD

ANESTHESIA: General with 0.5% Marcaine, 30 mL.

ESTIMATED BLOOD LOSS: Approximately 10 mL.

COMPLICATIONS: None.

DESCRIPTION OF OPERATION: The patient received IV antibiotics for prophylaxis, SCDs for DVT prophylaxis, Foley catheter intraoperatively. Under satisfactory general anesthesia, the abdomen was prepped and draped in the usual sterile fashion. A right inguinal incision was made through the skin and subcutaneous tissues. External oblique aponeurosis was incised and opened to the external ring, which immediately revealed a chronic undescended right testicle. Finger palpation toward the scrotum revealed no opening, and the spermatic cord was extremely thickened with a thickened hernia sac surrounding, measuring approximately 6 to 8 mm in thickness.

Due to the chronicity of the undescended testicle and the risk of testicular malignancy, orchiectomy was indicated. Distally, the gubernaculum was ligated with 2-0 Vicryl and divided. Proximally, the cord vessels and vas deferens were doubly ligated with 0 Vicryl and divided and specimen sent for pathologic evaluation. The thickened hernia sac was transected over a GIA stapler and the staple line oversewn with running 0 Vicryl suture. Mesh repair was then performed with Marlex suturing medially to pubic tubercle and Cooper ligament. Transition suture to the shelving edge of the inguinal ligament was performed. Medially, the mesh was sutured to the transversalis fascia and 0.5% Marcaine was infiltrated for local postoperative analgesia, and the external oblique was closed anterior with running 2-0 Vicryl. Scarpa fascia was closed with 3-0 Vicryl, and skin was closed with 4-0 Vicryl. Steri-Strips and bandage applied.

The patient tolerated the procedure well without complications and returned to the recovery room in satisfactory condition. All sponge, needle and instrument counts were correct following the procedure. The patient was discharged home with local wound care instructions and oral analgesics.

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PREOPERATIVE DIAGNOSIS: Left renal mass.

POSTOPERATIVE DIAGNOSIS: Left renal cell carcinoma.

OPERATION PERFORMED: Cryoablation of lesion.

SURGEON: John Doe, MD

ESTIMATED BLOOD LOSS: Minimal.

DRAINS: Foley catheter.

INDICATION FOR OPERATION: The patient was found to have an incidental left renal mass measuring roughly 3 cm in size. The patient was counseled as to the various options and chose to undergo cryoablation of the lesion rather than any type of excision of the mass or radical nephrectomy. The patient was warned of the risks of recurrence of disease and need for careful monitoring. He understood and wished to proceed. The patient was also warned of the possibilities of need for removal of the kidney during surgical exploration. The patient understood and wished to proceed.

DESCRIPTION OF OPERATION: The patient was brought to the operating room after anesthesia was placed in the supine position. He was prepped and draped in the sterile fashion. A midline periumbilical incision was made and carried into the peritoneal cavity. A gel pack was sized and appropriately placed and the seal created. After this was performed, through the seal the peritoneal cavity was insufflated with carbon dioxide. Following this, the port was placed for visualization. Two other separate small incisions were made in the anterior abdomen, and using the self-dilating ports, two other access ports were placed under visual inspection. No evidence of bowel injury was noted.

At this point, dissection was carried laterally to the white line of Toldt on the left side, and the dissection was carried down to the Gerota fascia, which was then carefully examined. The left renal mass could be palpated, and dissection of the Gerota fascia overlying the mass was performed. Following this, a separate stab wound was made in the flank and through the stab wound a biopsy gun placed. Under careful visualization, the tip of the biopsy probe was placed within the renal mass. Two biopsies were taken and sent for pathology, where frozen section confirmed the diagnosis of renal cell carcinoma.

At this time, a 2 cm cryoprobe was then placed through that separate incision into the renal mass. Freezing of the mass was then performed, two cycles with a freeze of six minutes followed by a passive thaw, followed by a second freeze with an active thaw with helium. Following completion, the probe was removed, and the hole was filled with FloSeal. Then, the whole mass packed over with Gelfoam. The lesion was then inspected for a while and no evidence of bleeding noted.

Bowel reapproximated in the previous normal anatomical position. Under visualization, we removed the ports and then the gel pack. We then closed the midline incision with a running #1 PDS stitch. Skin was closed with staples. The patient was injected with 0.5% Marcaine. He was then awakened and brought to the recovery room in stable condition.

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PREOPERATIVE DIAGNOSIS: Bladder neoplasms.

POSTOPERATIVE DIAGNOSIS: Bladder neoplasms.

OPERATION PERFORMED: Transurethral resection of the bladder (large).

SURGEON: John Doe, MD

ANESTHESIA: General.

INDICATIONS FOR OPERATION: This patient is a (XX)-year-old woman with severe pelvic and bladder pain, refractory to antibiotic therapy. Her urinalysis and urine cultures were negative. Cystoscopy demonstrated marked inflammatory changes of the right and left lateral bladder wall, localized. Bladder biopsy was consistent with acute and chronic inflammation. In light of the suspicious appearance for carcinoma in situ, we recommended proceeding with further diagnostic resection to rule out carcinoma in situ. The risks of bleeding, infection, and bladder perforation were described to the patient.

OPERATIVE FINDINGS: Marked acute and chronic inflammatory changes of both lateral walls, approaching the midline, away from the trigone. There were no papillary lesions.

DESCRIPTION OF OPERATION: After obtaining adequate general anesthesia, the patient was placed in the dorsal lithotomy position. The genitals were prepped with Betadine and draped with sterile drapes. Cystoscopy with 21-French cystoscope demonstrated the findings above. The cystoscope was removed and was replaced with a 25-French continuous flow resectoscope sheath using a Timberlake obturator. The obturator was exchanged for a bipolar resectoscope device.

Starting on the patient’s left side, an area of approximately 5 cm was resected into the muscle, taking care not to perforate the bladder. The entire resection site was fulgurated as well as all the abnormal mucosa.

Attention was then turned to the right lateral and posterior bladder walls where a similar lesion was identified. Similar resection was carried out in this area, once again taking care not to perforate. The resection site and the surrounding mucosa were fulgurated for hemostasis.

The resectoscope was removed and was replaced with a 20-French Foley catheter. Urine was clear. The patient tolerated the procedure well and was transferred to the recovery room in satisfactory condition.

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REFERRING PHYSICIAN: John Doe, MD

REASON FOR CONSULTATION: Elevated creatinine.

HISTORY OF PRESENT ILLNESS: This is a very pleasant (XX)-year-old female who was admitted with coffee-ground emesis and is showing black tarry stools and anemia. The patient was also admitted with a blood pressure of 178/98, tachycardia, and fever. The patient’s creatinine was found to be elevated at 2.3. We are asked to assist with her care. Unfortunately, the patient is demented and cannot give any history at this time. Her baseline mental status is unknown, but at this time, she does not respond to questions. Old records from 10 days ago show that her creatinine was 2.1 at that time. We have looked as far back as three years ago, which shows that her creatinine was 1.9 at that time.

PAST MEDICAL HISTORY: Apparently, from the chart, dementia; degenerative joint disease; anemia; dysphagia; and status post cesarean section.

MEDICATIONS: Senokot, Actonel, Oxytrol, Seroquel, Lexapro, omeprazole, vitamin D, and Os-Cal.

ALLERGIES: NKDA.

FAMILY HISTORY: Unknown.

SOCIAL HISTORY: The patient apparently does not use tobacco or alcohol.

REVIEW OF SYSTEMS: Unobtainable.

PHYSICAL EXAMINATION:
VITAL SIGNS: The patient’s blood pressure has improved to 168/74, pulse 94, and respiratory rate 18.
GENERAL: The patient is sleepy, not answering questions, and is in no distress.
HEENT: Pupils are reactive, symmetric. Oropharynx: Difficult to examine. Appears to be moist.
NECK: No JVD or lymphadenopathy.
HEART: Regular rate and rhythm.
ABDOMEN: Soft. Positive bowel sounds. No guarding or rigidity. No grimacing.
EXTREMITIES: No clubbing, cyanosis or edema.

LABORATORY DATA: Hemoglobin today has dropped to 8. The patient is being seen by Dr. Jane Doe. Her creatinine was stable at 2.3. Amylase and lipase are negative. Urinalysis demonstrates 1+ albumin and specific gravity of 1.015, otherwise within normal limits.

DIAGNOSTIC DATA: Chest x-ray images are reviewed. They show a left lung base opacity that is not traumatic. The abdomen shows a hiatal hernia and nonspecific bowel gas pattern.

ASSESSMENT:
1. Coffee-ground emesis.
2. Chronic renal insufficiency, mild exacerbation, likely due to gastrointestinal bleed.
3. Anemia.
4. Hypertension, uncontrolled.

PLAN:
1. Control hypertension.
2. Urine indices, renal osteodystrophy panel, iron studies.
3. Procrit to begin today.
4. The patient is hemodynamically stable, has been placed on proton pump inhibitors, and will likely need endoscopy soon.

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REFERRING PHYSICIAN: John Doe, MD

REASON FOR CONSULTATION: Dialysis management.

HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old African-American female with a past medical history of diabetes type 2; coronary artery disease, status post five-vessel coronary artery bypass surgery with a recent heart catheterization earlier this year that showed patent grafts; end-stage renal disease, on hemodialysis Monday, Wednesday, and Friday. The nephrologist is using a right-tunneled internal jugular venous catheter and an immature left upper extremity graft. The patient also has a history of peripheral vascular disease and CVA. She was admitted to the hospital for chest pain to rule out acute myocardial infarction. The patient reports that following her dialysis, last Wednesday, she developed worsening shortness of breath overnight, and following daytime activity and exertion, she started experiencing nonradiating central chest pain not associated with diaphoresis, nausea or lightheadedness. Therefore, she decided to come to the emergency department. She is pain-free now following her hemodialysis today. This morning, her shortness of breath was much improved. She was seen in consultation with Cardiology who advised maximizing medical management and no further inpatient cardiac workup indicated. Currently, the patient feels better with no shortness of breath, orthopnea, no chest pain, no palpitations, and no dizziness. She has had no nausea or vomiting. She makes minimal urine, and she denies dysuria or hematuria. Review of systems is otherwise unremarkable.

PAST MEDICAL HISTORY: As mentioned above, end-stage renal disease, on hemodialysis; diabetes mellitus type 2; hypertension; coronary artery disease, status post five-vessel coronary artery bypass, status post negative Myoview test last December and heart catheterization that showed patent graft earlier this year; history of peripheral vascular disease; and history of CVA.

PAST SURGICAL HISTORY: Cesarean section and multiple herniorrhaphies. History of left upper extremity arteriovenous fistula, last August, remains immature.

HOME MEDICATIONS: The patient is on Norvasc, Zocor, metoprolol, Aggrenox, Plavix, minoxidil, Diovan, Prevacid, Imdur, Procardia, and Darvocet.

ALLERGIES: No known drug allergies.

FAMILY HISTORY: Not contributory to renal evaluation.

SOCIAL HISTORY: The patient lives at home with family. The patient denies tobacco or alcohol use.

PHYSICAL EXAMINATION:
GENERAL: The patient is currently not in apparent distress. She is alert and oriented x3.
VITAL SIGNS: Blood pressure 146/66, heart rate 88, oxygen saturation 94% on room air.
HEENT: Atraumatic and normocephalic. No scleral icterus. Pupils are equal, round and reactive to light. Extraocular movements are intact. Oropharyngeal examination is unremarkable.
NECK: Shows no JVD, no lymphadenopathy, no carotid bruits, no thyromegaly.
LUNGS: Clear to auscultation bilaterally.
CARDIAC: Regular rate and rhythm. Audible S1, S2. No murmur, rub or gallop.
ABDOMEN: Soft, nontender. No palpable masses. No organomegaly. Bowel sounds are positive. No costovertebral angle tenderness.
EXTREMITIES: Show 1+ pitting edema. Decreased dorsalis pedis and posterior tibial artery pulsations bilaterally.
NEUROLOGICAL: Examination is grossly nonfocal.

LABORATORY DATA: Laboratories from yesterday showed hemoglobin of 12.4, normal white blood count and platelet count. Her electrolytes are within normal limits. BUN is 21, creatinine is 5.6, and albumin is 4. Cardiac enzymes x2 are negative. Urinalysis showed 3+ albumin, 2+ occult blood, 3+ leukocyte esterase, and 20-50 wbc’s with 1+ bacteria. Her TSH is normal.

DIAGNOSTIC DATA: Chest x-ray showed cardiomegaly, otherwise unremarkable findings.

IMPRESSION:
1. End-stage renal disease, on hemodialysis.
2. Chest pain ruled out for acute myocardial infarction. Rule out noncardiac causes.
3. Fluid overload.
4. Uncontrolled hypertension, largely secondary to fluid overload.
5. Diabetes mellitus type 2.
6. Coronary artery disease, status post coronary artery bypass graft with patent grafts per cardiac catheterization done earlier this year.
7. History of peripheral vascular disease with immature left upper extremity arteriovenous fistula.

PLAN: We have postponed her discharge today due to significant fluid overload and uncontrolled hypertension. The patient will benefit from repeat dialysis tomorrow to achieve dry weight and prevent recurrence of shortness of breath and chest pain. We have also asked the GI team to evaluate for noncardiac causes for chest pain. In the meantime, continue pantoprazole and famotidine. We might be able to discontinue some of the direct vasodilators and antihypertensive medications with adequate fluid removal at dialysis. Further recommendations as the clinical status and laboratory results might dictate.

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REFERRING PHYSICIAN: John Doe, MD

REASON FOR CONSULTATION: Hematuria.

HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old Hispanic female who started having blood in the urine four days ago. She took two antibiotics without improvement. Associated symptoms are right flank pain as well as dysuria, urinary frequency and urgency. The patient was admitted because of hemoglobin of 8.4. She was also noted to be in renal failure with a creatinine of 5.8. CT scan showed a stone in the left kidney without obstruction. No obstruction on either side noted or metastatic disease noted. The patient has a history of metastatic colon cancer.

PAST MEDICAL HISTORY: Metastatic colon cancer, status post left colectomy and chemotherapy with apparently 5-FU.

MEDICATIONS ON ADMISSION: Darvocet, Ziac, Soma, and lisinopril.

SOCIAL HISTORY: The patient denies tobacco, alcohol or illegal substance abuse.

ALLERGIES: PENICILLIN.

REVIEW OF SYSTEMS: Positive for some malaise. No fever or chills. No headaches or seizures. No visual changes or eye pain. No hearing problems or earaches. No chest pain or palpitations. No shortness of breath or wheezing. No nausea, vomiting or abdominal pain. For GU, see above. The patient denies any backaches or arthralgia. No bleeding tendency but a history of anemia. No allergies or frequent infections. No anxiety or depression. No diabetes or thyroid disease.

PHYSICAL EXAMINATION:
VITAL SIGNS: The patient is afebrile. Heart rate, respirations, and blood pressure all well controlled.
GENERAL: The patient is in no apparent distress, although she appears slightly somnolent.
HEAD AND NECK: Exam showed that she is normocephalic and atraumatic. Neck is supple. Trachea is in midline. No JVD noted.
LUNGS: Respirations unlabored. No audible wheezing or rhonchi.
ABDOMEN: Soft, nondistended, nontender. Scars from previous surgeries. Bladder is not palpable.
EXTREMITIES: Show full range of motion x4.
NEUROLOGIC: No focal neurological deficits noticed.
SKIN: Warm, dry, and appears to be intact.

LABORATORY DATA: Results are reviewed. CBC shows a WBC of 15.6, hemoglobin 8.4, hematocrit 25.4, and platelet count 384,000. Differential shows 81.6% neutrophils. Chemistry shows normal electrolytes. BUN 74, creatinine 5.8. Liver function is elevated. Urinalysis showed specific gravity of 1.020, pH 7.5, 2+ albumin, 1+ glucose, 1+ ketones, 2+ bilirubin, 3+ occult blood, positive nitrites, positive urobilinogen, 1+ leukocyte esterase. Microscopic shows more than 50 rbc’s per high power field, 5 to 10 wbc’s per high power field, and 1+ bacteria.

DIAGNOSTIC DATA: CT scan shows left kidney stones without obstruction. No obstruction or other stones noted. Metastatic disease and lymphadenopathy noted.

IMPRESSION AND RECOMMENDATIONS: Probable urinary tract infection with hematuria and left kidney stone, which is nonobstructing. Renal failure, possibly due to dehydration. The patient currently refuses Foley catheter. The patient is voiding spontaneously and states that she is emptying the bladder well. The CT scan shows what appears to be a clot in the bladder. Recommend antibiotic coverage. Monitor blood levels. Hydrate and continue antibiotic therapy.

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REFERRING PHYSICIAN: John Doe, MD

REASON FOR CONSULTATION: Renal failure, oliguria.

HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old female who has multiple medical problems, who was transferred here because of altered level of consciousness. The patient has problems, which started back in January when she had a prolonged hospitalization course. The patient had cardiac arrest at that time and acute renal failure for which she needed temporary dialysis. The patient was off dialysis, and her creatinine had been stable since. She also has a history of osteomyelitis of the right toe and had vertebral osteomyelitis and epidural placement. The patient had been admitted to an outside facility, and she has not been well for the past few days and recently has been diagnosed with Clostridium difficile colitis about a week ago. She was treated with antibiotics over there. She has been progressively getting worse with loose stool, and yesterday, she got worse with altered mental status and low blood pressure for which she was transferred here. In the ER, the patient was found to be very hypotensive. Her blood pressure, systolic, was in the 60s and 70s. She had received fluid bolus and was started on pressor support. She has received 2 or 3 liters of fluid bolus and is on pressor support with blood pressure, systolic, in the range of 90s and 100s. Her laboratory showed high BUN and creatinine and also she is not making much urine, which prompted renal consultation. Her laboratory about a week ago showed creatinine was within normal range. Currently, she is admitted to ICU and she is DNR with full active treatment.

PAST MEDICAL HISTORY: Significant for hypertension, history of diabetes, history of cardiac arrest, acute renal failure needing dialysis in January, history of recent Clostridium difficile colitis about a week ago, history of osteomyelitis, and staphylococcus infection in the past.

PAST SURGICAL HISTORY: She had left L3-4 laminectomy with epidural abscess drainage in July.

ALLERGIES: No known allergies.

MEDICATIONS: She has been on multivitamin, Norvasc, Remeron, aspirin, fentanyl, Lasix, Imdur, Lactinex, and oxycodone.

SOCIAL HISTORY: She has a history of smoking about 6 to 7 cigarettes per day. No alcohol use.

FAMILY HISTORY: Noncontributory.

REVIEW OF SYSTEMS: As per HPI. Most of the information is obtained from the chart and review of chart.

PHYSICAL EXAMINATION:
GENERAL: On examination, this is an elderly female who is lethargic and arousable.
VITAL SIGNS: Now, blood pressure is 102/62, heart rate is 88, and temperature is 97.4 degrees.
HEENT: Normocephalic and atraumatic. Pupils are reacting sluggishly. She has got NG tube in place.
NECK: Supple.
LUNGS: Bilateral air entry with some diminished breath sounds at the bases.
HEART: Sounds are regular with no murmur noted.
ABDOMEN: Tender all over, mildly distended. Bowel sounds are diminished.
EXTREMITIES: Show no edema.
NEUROLOGIC: Examination not done at this time.
SKIN: Dry, intact.

LABORATORY AND DIAGNOSTIC DATA: White count is 60, hemoglobin 10.3, hematocrit 31.6, and platelets 466. Her sodium is 129, potassium is 5.5, chloride is 96, bicarbonate is 15, glucose 196, BUN/creatinine 82 and 3.4. BNP is 150. CT of the brain shows no acute changes.

IMPRESSION:
1.  A patient with altered mental status, likely toxic metabolic encephalopathy.
2.  Sepsis syndrome with septic shock with low blood pressure, on pressors.
3.  Oliguric renal failure.
4.  Acidosis.
5.  Marked leukocytosis.
6.  Recent Clostridium difficile colitis.
7.  History of methicillin-resistant Staphylococcus aureus infection and bacteremia.
8.  History of cardiac arrest and acute renal failure in January.
9.  History of chronic left bundle branch block.

RECOMMENDATIONS: Acute renal failure, likely secondary to the above, likely secondary to sepsis and volume depletion and medication use with possibility of going into ATN. At this time, agree with fluid resuscitation and pressor support. The patient is acutely ill at this time. She has been started on broad-spectrum antibiotic coverage. We will repeat her chemistry and follow up on the potassium level and add bicarbonate as needed. Cultures have been ordered. We have discussed the case with the family, and we will dialyze the patient if needed. No need of dialysis at this point. We will follow closely. Further recommendations and plans as we go along.

Thank you for the consultation and for allowing us to participate in this patient’s care.

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