Urology Case Study

DISCHARGE SUMMARY

DIAGNOSIS

Chronic renal failure with uremia.

BRIEF HISTORY

The patient is a 19-year-old male with 2-week history of gradually increasing weakness, malaise, fatigue.  He was seen, evaluated in the office, and had a panel drawn.  This revealed marked abnormalities consistent with chronic renal failure, near end-stage.  He was brought to the hospital and admitted.

Physical examination revealed his vital signs to be stable.  HEENT revealed no acute changes.  Pallor was noted.  Chest clear.  Heart:  Regular rate and rhythm.  Abdomen:  Moderate obesity.  Extremities unremarkable.

Laboratory revealed diffuse abnormalities.  Glucose 130, BUN 195, creatinine 26.0, Sodium 134, potassium 4.1, chloride 94.  Calcium 5.1.  Uric acid 10.2.  Phosphorus 14.  Triglycerides 300.  LDH 279.  Hemoglobin 8.9, hematocrit 26.5.  Urinalysis revealed
4+ protein, 10 to 20 wbc’s.

HOSPITAL COURSE

Nephrology consultation was obtained.  Arrangements were made for transfer of the patient for dialysis.  CT scan was obtained which revealed small atrophic kidneys bilaterally.

DISPOSITION

The patient was transferred for immediate dialysis.  Followup is to be arranged by nephrologist.

FOOTNOTE

Line 26.  Alternative:  10-20.  White blood cells are written in small and the plural is written with an apostrophe.  WBC is for white blood count.