tokens: 920798564 CTMC 70160673 840502 3/3/1999 12:00:00 AM PROSTATE CANCER AND RENAL FAILURE Signed DIS Admission Date : 03/03/1999 Report Status : Signed Discharge Date : 03/08/1999 PRINCIPAL DIAGNOSIS : ACUTE RENAL FAILURE . SIGNIFICANT PROBLEMS : 1. METASTATIC PROSTATE CA . 2. OBSTRUCTIVE UROPATHY , STATUS POST LEFT NEPHROSTOMY . 3. HYPERTENSION . 4. ANEMIA . 5. GASTROESOPHAGEAL REFLUX DISEASE . CHIEF COMPLAINT : This 88-year-old male with history of prostate CA was admitted from an outside hospital secondary to persistent hematuria status post nephrostomy tube placement transferred to Retelk County Medical Center for further management . HISTORY OF PRESENT ILLNESS : Mr. Prehekote is an 88-year-old Portuguese speaking only male who was diagnosed with adenocarcinoma of the prostate in 1998 . He received transurethral resection of the prostate one year ago because of persistent urinary retention . After that , he was on Lupron and Nilandron hormone therapy . The patient was admitted on February 23 , 1999 to Eifro Medical Center because of failure to thrive and decreased hematocrit . He was noted to have elevated BUN and creatinine . BUN was 34 and creatinine was 2.6 , up from his baseline of 1.0 . Prostate specific antigen increased from 77.9 to 88 , and the patient also had urinary incontinence and body weight loss . Further evaluation of his renal failure showed that the patient has bilateral hydronephrosis , most likely obstructive uropathy due to prostate CA in the pelvic area . Because of the increasing creatinine to 8.0 on February 28 , 1999 , a left nephrostomy tube was placed . However after the procedure , the patient &apos;s hematocrit dropped to 24 and he was transfused two units of packed red blood cells . His hematocrit increased to about 30 , but he continued to have hematuria and his renal function only improved very slowly . He also received Kayexalate for hyperkalemia . Due to the persistent blood in the urine , he was transferred from Eifro Medical Center to the Retelk County Medical Center for angiographic studies to rule out any vascular injuries . The patient was transferred to Genearocktemp Ry Health on March 3 , 1999 . REVIEW OF SYSTEMS : The patient had constipation with dysuria , but no fever or chills . No cough . No chest pain . No palpitations , history of epigastric pain and body weight loss . No headache . No bone pain . PAST MEDICAL HISTORY : 1) Hypertension . 2) Gastroesophageal reflux disease . 3) Anemia . 4) Prostate CA . ALLERGIES : No known drug allergies . MEDICATIONS : Clonidine 2.5 milligrams topical q. week , Nitropaste 2 inches q.4h. , Nilandron 50 milligrams p.o. q.d. , Lupron , Dulcolax p.r.n. , Colace 100 milligrams p.o. b.i.d. , Ferrous sulfate 300 milligrams p.o. b.i.d. , Lansopiacole 15 milligrams p.o. q.d. , bethanechol 25 milligrams p.o. t.i.d. SOCIAL HISTORY : The patient has been living in the Kansas for more than 20 years . He was originally from Wark and he speaks Portuguese only . He is now living with his son and daughter , and five other children . PHYSICAL EXAMINATION : On admission , the patient was a frail looking elderly male lying in bed in no acute distress . Temperature 95.4 , pulse 120 , blood pressure 150/80 , respiratory rate 24 , 95% on room air . Conjunctiva were not pale . Sclera nonicteric . Pupils : Isocoric cataract bilaterally . Mouth : Mucous membranes slightly dry . No oral ulcers . Neck : Supple . Jugular vein not engorged . Carotid pulses bounding very strongly . No thyromegaly . Chest examination showed some basilar crackles at the right lung base . Heart initially tachycardia , grade II / VI systolic ejection murmur at the left sternal border . Abdomen : Soft . Liver and spleen were not palpable . Bowel sounds normoactive . Extremities : Traced pitting edema . No cyanosis and no clubbing . Peripheral pulses were very strong and bounding . No calf tenderness . Homan &apos;s sign negative . Neurologic : Examination was limited because the patient speaks only Portuguese . LABORATORY DATA : On admission the patient &apos;s biochemistry showed sodium of 140 , potassium 4.0 , chloride 107 , bicarb 14 , BUN 63 , creatinine 5.8 , blood sugar 133 . Liver function test showed AST 21 , alkaline phosphatase 70 , total bilirubin 0.3 , total protein 6.5 , albumin 3.9 , globulin 2.6 . CBC : WBC 8.4 , hematocrit 32.6 , platelet count 194,000 . PT 11.9 , INR 1.0 , PTT 28.4 . Chest x-ray showed no evidence of cardiomegaly . No lung infiltrate . CT scan of the renal area showed right hydronephrosis which extends to an asymmetrically thickened urinary bladder wall . A mass like thickening of the urinary bladder suggestive of either detrusor hypertrophy or possibly tumor . The CT scan showed a cavitary lung lesion in the right lower lobe compatible with metastatic or septic embolus . EKG showed atrial fibrillation , left axis deviation , LVH , nonspecific ST-T changes either due to digitalis affect . CK enzymes 146 . Repeated three times and remained flat . Troponin I on the second day of admission was 1.18 . HOSPITAL COURSE : After admission , urology , nephrology as well as interventional radiology was consulted about the management of this patient . The specialist concluded that because the patient &apos;s hematuria seemed to be stable and hematocrit to maintain at about 29-30 , there is no urgent need to do an arteriogram which may cause further damage to the patient &apos;s kidney . Urology consultation thinks that cystoscopy would not add any benefit to the management and only would consider a right nephrostomy if renal function failed to improve . After admission , the patient was treated conservatively to correct his electrolyte and metabolic acidosis . He was given blood transfusion , two units when his hematocrit dropped to 29.4 . After transfusion , the patient &apos;s hematocrit rose to 37.7 on the day of discharge . The patient was also given sodium bicarbonate to correct his metabolic acidosis . He continued to pass about 1500-2000 cc of urine a day and his renal function improved slowly with creatinine decreased to 4.2 on the day of discharge . During this admission , the patient also developed atrial fibrillation with ventricular rate of about 70-80 . CPK was tracked , but was totally normal . No beta blockers were given . A long discussion amongst the specialist , nephrology , urology , interventional radiology , primary oncology as well with the family lead to the conclusion that conservative management may give the patient more comfort than crisis treatment in this well advanced prostate CA . Dr. Lucreamull discussed the patient &apos;s clinical status and overall situation with the patient &apos;s family and the family decided that Mr. Prehekote could return home with hospice . The patient &apos;s primary care physician , Dr. Tomedankell Flowayles will manage the hospice issues . The patient was discharged to home for hospice on March 8 , 1999 . DISCHARGE MEDICATIONS : Bethanechol 25 milligrams p.o. t.i.d. , Clonidine 2.5 milligrams topical q. week , apply every Sunday , Colace 100 milligrams p.o. b.i.d. , Haldol 0.5-1 milligrams p.o. q.6-8h. p.r.n. agitation , Niferex 150 milligrams p.o. b.i.d. , nitroglycerin paste 2% , 2 inches topical q.8h. , Prilosec 20 milligrams p.o. q.d. , Senna tablets 2 tablets b.i.d. , sodium bicarbonate 650 milligrams p.o. t.i.d. for five days , Proscar 5 milligrams p.o. q.d. , Casodex 50 milligrams p.o. q.d. , Nephrocaps 1 tablets p.o. q.d. COMPLICATIONS : None . CONDITION ON DISCHARGE : Fair . DISPOSITION : Home with hospice . Dictated By : KYMBELL SPARDJEB , M.D. BJ43 Attending : LAGEORG LUCREAMULL , M.D. MR28 PN199/1242 Batch : 14667 Index No. UDFTTQ73N9 D : 03/08/99 T : 03/09/99