We are asked to see Mr. Preston. He is a pleasant 70-year-old gentleman recently diagnosed with myeloma, who is found to have a creatinine around 2.0.
He appears to have been worked up in Florida for the creatinine around 2, and myeloma with 20% plasma cells was found. He was transferred here for chemotherapy. On review of his old record, he was diagnosed in the Butner systems based on our excellent electronic medical record in 02/2011 with hypertensive nephropathy. His 2009 creatinine was 1.5, 2010 his creatinine was 1.8. UA was normal. Ultrasound 10.5 cm kidneys. Fast forwarding to now in 10/2017, creatinine 1.9 (2.4), bicarb 23, potassium 4.0, sodium 140, calcium 8.2, AST 18, albumin 3.3. Urine microalbumin to creatinine ratio
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Hypertensive nephropathy advanced stage III, stable since 2010.
2. Myocardial infarction in 1996.
3. Stroke in 1993.
4. Multiple myeloma, diagnosed 08/2017.
5. Gastroesophageal reflux disease. He has been on Prilosec since 2004 and strongly feels that he needs it in order to prevent symptoms.
6. Sleep apnea.
7. Cataract.
8. Past hyperglycemia at times.
9. Coumadin
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PHYSICAL EXAMINATION
Blood pressure 136/75, weight 248, pulse 79, temp 97.6, O2 sat 100% sat on room air. Lungs: Clear. Extremities: 1+ edema bilaterally.
ASSESSMENT/PLAN
1. Hypertensive CKD, stable since 2010. I do not think that myeloma is involving the kidneys. No change in therapy needed.
2. Hypertension adequate control with the goal being to keep the systolic less than 140.
3. Edema. He has 1+ edema. I have counseled a low-salt diet and he is following it. If this does worsen, you could easily double his Lasix and even increase further.
4. Acidosis. An ideal bicarb is 23, that is where he is at and so continuing the sodium bicarb 1 a day is fine for now.
5. Calcium phosphorus likely fine. No Rx needed given the overall complexity of his care.
6. GERD. Controlled and he feels that he needs the omeprazole. He has been on it since 2004 and it is unlikely that it is causing kidney disease given his renal stability.
7. Anticoagulation. He is on Coumadin, possibly also Lovenox, I am not sure of the reason and defer to the primary team.
8. Gout. He had a severe attack. I believe that was on allopurinol, if it was and his uric acid level is 11 on current dose of allopurinol, then the allopurinol could be increased to 300 daily or he could be changed to Uloric 80