Century Consulting- Chronological Report

Date	Provider	Bates	Objective	Testing	Medication
4/20/01 Northwest Clinic	Dr. Z	000062	Patient was admitted to X Medical Center for dialysis yesterday. He apparently developed acute renal failure. It is quite likely this is due to rhabdomyolysis, which may be a consequence of the lipid-lowering medicines he's on, although it's not clear at this time. I did visit him at X Medical Center and spent about an hour with him discoursing on the fact that I thought the lipid medications may be a factor here and that his long-term prognosis was fairly good. I did go through various aspects of grieving, particularly for people on dialysis. Fortunately, at this time he's been laid off from work with a severance package, so he's not losing work. I tried to answer all of his and his wife's questions. I note he had a normal CPK in November and normal LFT's as early as March 2001.	GLUCOSE 206 60-110 MG/DL BUN 160 7-24 MG/DL CREATININE 12.8 0.5-1.2 MG/DL CALCIUM 6.8 8.8-10.8 MG/DL SODIUM 133 135-148 MMOUL POTASSIUM 7.6 3.5-5.0 MMOUL CHLORIDE 95 98-112 MMOUL CARBON DIOXIDE 16 22.0-31.0 MMOUL ALK PHOS. 70 39-117 U/L AST 676 12-32 U/L ALT 581 0-40 U/L ALBUMIN 2.5 3.2-5.2 G/DL TOTAL PROTEIN 5.0 5.9-8.4 G/DL 000042
4/20/01 X Medical Center	Signature illegible	000022-3	Assessment/Plan: 1. Acute Renal Failure – requiring dialysis. Most likely this is intrinsic renal failure secondary to rhabdomyolysis due to combination treatment of Baycol and Gemfibrozil. Will probably need dialysis everyday for the next few days. 2. Increased liver function: Continues to decrease. There are several possible contributing factors. Due to decreased perfusion but statins also have liver toxicity effects. The liver function is normal. Will continue to monitor. 3.Rash: more extensive today than yesterday. It is non-pruritic, not really consistent with uremia. Probably drug rash. 4.Hypertension: continue Norvasc & Beta Blocker. 5.Hyperlipidemia: Hold Baycol & Gemfibrozil. Will try to find more information if he can use these meds again. Will check lipid panel 6.Coronary Artery Disease: currently stable, asymptomatic	GLUCOSE 130 60-110 MG/DL BUN 120 7-24 MG/DL CREATININE 10.8 0.5-1.2 MG/DL CALCIUM 7.3 8.8-10.8 MG/DL SODIUM 132 135-148 MMOUL POTASSIUM 3.8 3.5-5.0 MMOUL CHLORIDE 97 98-112 MMOUL CARBON DIOXIDE 22 22.0-31.0 MMOUL ALK PHOS. 58 39-117 U/L AST 365 12-32 U/L ALT 371 0-40 U/L ALBUMIN 2.3 3.2-5.2 G/DL TOTAL PROTEIN 5.8 5.9-8.4 G/DL CPK 33,679 24.00-195.00 U/L 000042
4/21/01 X Medical Center	Signature illegible	000025	Nephrology Acute Renal Failure: associated with Rhabdomyolysis secondary to meds. Still with muscle pains. Small amount of urine output. BP: 170/100 Lungs clear. Heart regular. Assessment/Plan: Acute Renal Failure: Uremic – Dialysis dependent Hypertension: still present. Increased BP.	GLUCOSE 130 60-110 MG/DL BUN 120 7-24 MG/DL CREATININE 10.8 0.5-1.2 MG/DL CALCIUM 7.3 8.8-10.8 MG/DL SODIUM 132 135-148 MMOUL POTASSIUM 3.8 3.5-5.0 MMOUL CHLORIDE 97 98-112 MMOUL CARBON DIOXIDE 22 22.0-31.0 MMOUL ALK PHOS. 58 39-117 U/L AST 365 12-32 U/L ALT 371 0-40 U/L ALBUMIN 2.3 3.2-5.2 G/DL TOTAL PROTEIN 5.8 5.9-8.4 G/DL CPK 33,679 24.00-195.00 U/L 000042
4/21/01 X Medical Center	Dr. ZZ	000025	Patient seen in dialysis earlier. He states muscle aches in back of legs is improving. BP: 163/91 Skin: erythema lower abdomen decreased Assessment/Plan: Acute Renal Failure Hypertension Increased transaminases Hyperlipidemia
4/22/01 X Medical Center	Signature illegible	000027	Nephrology Acute Renal Failure – Rhabdomyolysis – Oliguria Fever a little better – less hiccups. Intermittent nausea – no emesis. BP okay on floor – up this morning 170/100 Lungs: clear Heart: regular Abdomen: soft Extremities: no edema Assessment/Plan: Uremia stabilizing with daily dialysis. He will continue daily hemodialysis at least for one more day after today. Hypertension – high in dialysis	GLUCOSE 105 60-110 MG/DL BUN 87 7-24 MG/DL CREATININE 9.1 0.5-1.2 MG/DL CALCIUM 8.0 8.8-10.8 MG/DL SODIUM 134 135-148 MMOUL POTASSIUM 3.5 3.5-5.0 MMOUL CHLORIDE 97 98-112 MMOUL CARBON DIOXIDE 26 22.0-31.0 MMOUL ALBUMIN 2.5 3.2-5.2 G/DL TOTAL PROTEIN 5.8 5.9-8.4 G/DL 000042
4/22/01 XMedical Center	Signature illegible	000028	Pain decreasing significantly. No nausea/ pruritus /bleeding. BP: 150/90 Pulse: 80 regular Assessment/Plan: --Acute Renal Failure – hemodialysis per renal, anticipate good prognosis after course of out patient hemodialysis Started Amphojel x 3 days --Rhabdomyolysis – improving. Questionable if statins alone is safe in future. --Anemia – mild, normocytic. Observe trend. --Increased liver function tests – attributed to “shock liver” secondary to same reaction that caused rhabdomyolysis
4/23/01 X Medical Center	Dr. ZZ	000030–31	Feeling better. Decreased muscle pain. BP 147/73 to 202/102 Assessment/Plan: --Acute Renal Failure: improving creatinine. On dialysis everyday. Await recommendation from nephrology regarding duration or frequency of dialysis --Low serum albumin: likely secondary to proteinuria. --Increased liver function tests: Continues to decrease. Expect level to gradually normalize. Etiology? “shock liver” ? Pt never has hypotension and was fluid overload on admission --Hypertension: very elevated BP this morning. Patient is on Metoprolol and Norvasc. Will increase Metoprolol to 100 mg twice a day. Also nitro paste as needed. --Rhabdomyolysis: resolving. It is probably okay for patient to be started on Gemfibrozil or statins independently Disposition: await recommendations from nephrology. Would favor Lipitor to decrease cholesterol and triglycerides as monotherapy. At maximum dose of Norvasc. Can try to increase Metoprolol for BP control.	LUCOSE 136 60-110 MG/DL BUN 64 7-24 MG/DL CREATININE 7.7 0.5-1.2 MG/DL CALCIUM 8.1 8.8-10.8 MG/DL SODIUM 132 135-148 MMOUL POTASSIUM 3.7 3.5-5.0 MMOUL CHLORIDE 94 98-112 MMOUL CARBON DIOXIDE 25 22.0-31.0 MMOUL ALK PHOS. 63 39-117 U/L AST 194 12-32 U/L ALT 222 0-40 U/L ALBUMIN 2.5 3.2-5.2 G/DL TOTAL PROTEIN 4.9 5.9-8.4 G/DL 000042

Nephrology