REASON FOR CONSULTATION:  Renal failure.

HISTORY OF PRESENT ILLNESS:  Thank you for referring Ms. Abc to ABCD Nephrology.  As you know she is a 51-year-old lady who was found to have a creatinine of 2.4 on a recent hospital admission to XYZ Hospital.  She had been admitted at that time with chest pain and was subsequently transferred to University of A and had a cardiac catheterization, which did not show any coronary artery disease.  She also was found to have a urinary tract infection at that time and this was treated with ciprofloxacin.  Her creatinine both at XYZ Hospital and University of A was elevated at 2.4.  I do not have the results from the prior years.  A repeat creatinine on 08/16/06 was 2.3.  The patient reports that she had gastric bypass surgery in 1975 and since then has had chronic diarrhea and recurrent admissions to the hospital with nausea, vomiting, diarrhea, and dehydration.  She also mentioned that lately she has had a lot of urinary tract infections without any symptoms and was in the emergency room four months ago with a urinary tract infection.  She had bladder studies a long time ago.  She complains of frequency of urination for a long time but denies any dysuria, urgency, or hematuria.  She also mentioned that she was told sometime in the past that she had kidney stones but does not recall any symptoms suggestive of kidney stones.  She denies any nonsteroidal antiinflammatory drug use.  She denies any other over-the-counter medication use.  She has chronic hypokalemia and has been on potassium supplements recently.  She is unsure of the dose.  

PAST MEDICAL HISTORY: 
1.  Hypertension on and off for years.  She states she has been treated intermittently but lately has again been off medications.
2.  Gastroesophageal reflux disease.
3.  Gastritis.
4.  Hiatal hernia.
5.  H. pylori infection x3 in the last six months treated.
6.  Chronic hypokalemia secondary to chronic diarrhea.
7.  Recurrent admissions with nausea, vomiting, and dehydration.  
8.  Renal cysts found on a CAT scan of the abdomen.
9.  No coronary artery disease with a recent cardiac catheterization with no significant coronary artery disease.  
10.  Stomach bypass surgery 1975 with chronic diarrhea.
11.  History of UTI multiple times recently.
12.  Questionable history of kidney stones.
13.  History of gingival infection secondary to chronic steroid use, which was discontinued in July 2001.
14.  Depression.
15.  Diffuse degenerative disc disease of the spine.
16.  Hypothyroidism.
17.  History of iron deficiency anemia in the past.  
18.  Hyperuricemia.  
19.  History of small bowel resection with ulcerative fibroid.  
20.  Occult severe GI bleed in July 2001.

PAST SURGICAL HISTORY:   The patient has had multiple surgeries including gastric bypass surgery in 1975, tonsils and adenoidectomy as a child, multiple tubes in the ears as a child, a cyst removed in both breasts, which were benign, a partial hysterectomy in 1980, history of sinus surgery, umbilical hernia repair in 1989, cholecystectomy in 1989, right ear surgery in 1989, disc surgery in 1991, bilateral breast cysts removal in 1991 and 1992, partial intestinal obstruction with surgery in 1992, pseudomyxoma peritonei in 1994, which was treated with chemotherapy for nine months, left ovary resection and fallopian tube removal in 1994, right ovarian resection and appendectomy and several tumor removals in 1994, surgery for an abscess in the rectum in 1996, fistulectomy in 1996, lumbar hemilaminectomy in 1999, cyst removal from the right leg and from the shoulder in 2000, cyst removed from the right side of the neck in 2003, lymph node resection in the neck April 24 and biopsy of a tumor in the neck and was found to be a schwannoma of the brachial plexus, and removal of brachial plexus tumor August 4, 2005.  

CURRENT MEDICATIONS: 
1.  Nexium 40 mg q.d.
2.  Synthroid 1 mg q.d. 
3.  Potassium one q.d., unsure about the dose.  
4.  No history of nonsteroidal drug use.

ALLERGIES:   Sulfa causes hives.  

TRANSFUSIONS:   Transfusion in 1993.

FAMILY HISTORY:  Mother is deceased at the age of 55 of breast cancer and also had type 2 diabetes.  Father is deceased of known cause.  Strong family history of diabetes in the mother, grandmother, sisters, maternal aunts, and uncles. 

SOCIAL HISTORY:   She works as a cook for a nursing home, is single and has one daughter.  Never smoked.  Denies any alcohol.  Has not been sexually active in a long time.  

REVIEW OF SYSTEMS:  Positive for 5-6 pound weight loss in recent months.  Poor appetite.  She wears glasses.  She complains of a funny sensation in the throat and clearing her throat all of the time.  GI:  She has recurrent nausea.  Currently, has no active vomiting.  Chronic diarrhea since the time of the bypass with eight watery stools per day.  She has joint aches and has all of the time spasms in both legs.  Has had cysts removed in both breasts and recent mammogram in March 2006 was normal.  History of depression and high stress with multiple psychosomatic complaints in the past.  She reports that her fingersticks were high in the hospital and subsequently were rechecked and were normal.  History of iron deficiency anemia in the past.  Allergies:  Sulfa causes hives.  

PHYSICAL EXAMINATION:  An overweight cushingoid-looking lady in no acute distress.  WEIGHT:  170 pounds.  TEMPERATURE:  96.7.  BLOOD PRESSURE:  130/84.  RESPIRATIONS:  12.  PULSE:  62.  HEENT:  Conjunctivae are anicteric.  Lids have no ptosis.  Pupils are equal, round, and reacting to light.  Optic disks are flat.  No hemorrhages.  ENT:  Appear normal.  Mucosa is moist.  NECK:  Supple.  No JVD.  No thyromegaly.  LUNGS:  Clear to auscultation.  CARDIOVASCULAR:  Normal heart sounds and 1/6 ejection systolic murmur.  PULSES:  All peripheral pulses are present.  EXTREMITIES:  No peripheral edema.  BREASTS:  Inspection of the breasts is normal.  ABDOMEN:  Soft and nontender.  Normal bowel sounds.  Multiple surgical scars.  Multiple striae.  No bruit.  No hepatosplenomegaly.  LYMPHATIC:  No neck, axillary, or groin lymphadenopathy.  MUSCULOSKELETAL:  Gait and station are normal.  No clubbing or cyanosis.  SKIN:  No rashes.  NEUROLOGICAL:  Cranial nerves are intact.  Deep tendon reflexes are 2+.  Strength is 5/5.  PSYCHIATRIC:  Judgment and insight are good.  Orientation to time, place, and person is normal.  

LABORATORY DATA:  Laboratory data on 08/16/06:  BUN 15, creatinine 2.3, sodium 142, potassium 3.4, chloride 102, uric acid 9.2, and albumin 3.9.