A patient with worsening acute renal failure following CABG
CC : Follow-up ARF
Interval History: The patient’s ARF has worsened since yesterday and he has become oliguric. Hypotension has resolved and in fact the patient is somewhat hypertensive today. He is POD #4 from four vessel CABG. Coronary disease has been stable with no evidence of ongoing ischemia.
Medications
Sliding scale insulin
Coreg 12.5 PO BID
, Lasix 40 mg PO QD
, KCL prn, per protocol
ROS
General--Positive for fatigue ; gative for fevers/chills
Cardiovascular—Positive for worsening edema; negative for chest pain, orthopnea or PND
GU-- Negative for flank pain, hematuria, dysuria, obstructive symptoms
Physical Exam
General: NAD, conversant, but somewhat anxious
Vitals: 160/90, 65, 98.6
HEENT: OP clear with MMM, No JVD
Lungs: CTA in front with faint bibasilar crackles in back
CV: RRR, with healing midline sternotomy
Extremities: 3+ bipedal edema; no digital cyanosis
Skin: Warm and dry with normal turgor; new rash or levido reticularis
Psyche: A&O times 3, with appropriate affect
Labs: BUN 67, creatinine 3.8, K 5.7, HCO3 18, HGB 9.0, BNP 1750
Assessment
- Worsening oliguric ARF with hyperkalemia and metabolic acidosis
- Decompensated cardiomyopathy with evidence of CHF on exam
- Poorly controlled hypertension
- Worsening anemia
- CAD s/p CABG
Plan
- Stop oral furosemide
- Start bumex 2 mg IV Q6
- Chest X-ray in a.m.
- Recheck renal profile and CBC tomorrow
- Consider transfusion if HGB drops below 8.5
- No indication for dialysis today
- Patient and family updated at the bedside
For a detailed breakdown of this note with tips and advice see 99233 E/M Insight
|
