[Verified Answer]: HISTORY OF PRESENT ILLNESS: Linda is a…

HISTORY OF PRESENT ILLNESS: Linda is a 48-year-old white female who is known to have chronic renal failure, presumed to be related to lupus nephritis. Since approximately 7:30 P.M. last night, she has been having diarrhea at least four times an hour. Her diarrhea increased in the morning. I received a call from her husband in the early morning, and I advised them to come to the emergency room. She was thought to be dehydrated in the ED and was admitted. Her diarrhea is mostly loose. It does not seem to be explosive; minimal mucus, and no blood. It is associated with cramping, especially after she passes a bowel movement. She denies any fever or chills. She has no night sweats. This seems all to be acute and she did not have any problems with diarrhea before. She has no heartburn, nausea, or vomiting. She has seen a physician, who added to her medications, Mavik 4 mg q.d. and Catapres to treat her uncontrolled hypertension. The patient seemed frustrated with her care because she is taking five medications for high blood pressure, and she has been compliant with diet, but her blood pressure does not seem to be controlled. PAST MEDICAL HISTORY: Significant for the following: 1. Systemic lupus erythematosus, which seems to be inactive. 2. Chronic renal failure requiring dialysis for a few weeks and then recovery of her renal function documented with a creatinine clearance of 23 ml/min with a serum creatinine of 2.9 and urine creatinine of 76 mg/dl last month. She continues to have a right IJ tunneled dialysis catheter, but she has not been on dialysis for 3 weeks. The patient has been feeling good about that. She has been seen at the Jamaican Clinic and was started on CellCept 1 g b.i.d. 3. Also, the patient had a kidney biopsy done here under CT guidance. Unfortunately, no glomeruli were noted. Most of the two pieces of tissue submitted contained medulla. The patient had proteinuria up to 6 g in 24 hours. This is at the time when she had her kidney biopsy. She had only one kidney biopsy, and this has never been followed up. We do not have any diagnosis, unfortunately, at this time, and she has been treated empirically. 4. Uncontrolled hypertension with multiple medications and regimens back and forth for the past few months without any benefit. The patient still runs 160–180 systolic over 90–100 diastolic. 5.Restrictive lung disease. 6.Chronic anemia of kidney disease and probably of chronic disease. 7.History of bilateral flank pain of unclear etiology while she was on dialysis. It has never been worked up. 8.Multiple compression fractures with osteoporosis. 9.Hyperlipidemia. ALLERGIES: AMOXICILLIN. CURRENT MEDICATIONS: 1.Prednisone 10 mg q.d. 2.CellCept 500 mg 2 b.i.d. 3.Cozaar 50 mg 2 b.i.d. 4.Epogen 15,000 subcutaneously twice a week. 5.Nephrocaps 1 q.d. 6.Renagel 1 t.i.d with meals. 7.Norvasc 10 mg q.d. 8.Metoprolol XL 100 mg b.i.d. 9.Catapres patch 0.1 mg 2 patches once a week. 10.Tylenol PM. 11.Lasix 40 mg b.i.d. 12.Protonix 40 mg 1 q.d. 13.Mavik 4 mg 1 q.d. for the past week. SOCIAL HISTORY: The patient is a nonsmoker and nondrinker. She lives with her husband. FAMILY HISTORY: She has 3 sisters and 2 brothers, and most of them are hypertensive. Otherwise, her family history is noncontributory. REVIEW OF SYSTEMS: General: No fever, chills, night sweats, or recent weight change. ENT: Dryness in her mouth and nose, which is chronic. Eyes: Status post cataract surgeries. Neurologic: No numbness, tingling, headaches, or fainting spells. Respiratory: Chronic cough, occasional sputum production. No orthopnea or PNDs. Occasional leg edema. Cardiac: No chest pain, orthopnea, PNDs, leg edema, or claudication. GI: As mentioned in the HPI. GU: No frequency, urgency, hematuria, or nocturia. Skin: No recent rashes or itching. Endocrine: No diabetes or thyroid problems, but she has been on chronic steroid therapy. PHYSICAL EXAMINATION: On examination, the patient is lying in bed. She looks dry. She is not in any distress. Blood pressure is 180s/90s. She is afebrile. Respiratory rate is 16 per minute. Saturations are maintained on room air in the mid 90s. She has no increased jugular venous pressure. She has right IJ tunnel dialysis catheter. No cervical lymphadenopathy other than dry mucous membranes. ENT is negative. Lungs: Good air entry bilaterally without crackles. No sacral edema. 11⁄2 x 1⁄2 leg edema bilaterally. Abdomen is very soft and nontender. I cannot hear any renal bruits. Cardiac exam: Regular S1 and S2 without any murmurs or friction rubs. Neurologic: The patient is awake, alert, and oriented. Cranial nerves II–XII seem to be intact. Motor power is 5/5 bilaterally with normal gait. Spine straight.