Clogged AV Shunt - Consult 

REASON FOR CONSULTATION: , Clogged AV shunt.,HISTORY OF PRESENT ILLNESS:,  This is a 32-year-old African-American male who came to ABCD General Hospital with the above chief complaint.  The patient complains of fatigue, nausea, vomiting and fever.  The patient states that the shunt was placed in February, although according to medical records it was placed in April and it has been periodically clogging since its placement.  The patient had dialysis today, which is Saturday, for approximately one hour before the shunt no longer worked.  The patient had been seen in the Emergency Room yesterday, 08/29/03, by Dr. X for the same problem.  At that time, Dr. X felt that the patient should use the AV fistula during dialysis and after the fistula is able to be used, the PermCath on the right subclavian should be removed.  As mentioned above, he had dialysis today and they were unable to use AV fistula as well as the PermCath read "did not work".  The patient has had dialysis since January secondary to hypertension-induced renal failure.  He takes dialysis Monday, Wednesday, and Friday at the ABCD Dialysis Center.  He also was seen at XYZ and he had an apparent thrombectomy with reversal done a few days ago.  The patient's history at this point is a little sketchy; however, he states that he left AMA.  All other systems are reviewed and are negative.,PAST MEDICAL HISTORY: , Significant for heart attack, chronic renal failure with dialysis, CHF, hypertension, and PermCath.,PAST SURGICAL HISTORY: , AV fistula on the left arm and a PermCath.,ALLERGIES: , Penicillin.,MEDICATIONS: , Include metoprolol 100 mg two tablets b.i.d., Tylenol #3, Accupril 20 mg q.d., digoxin, Renocaps, aspirin, and Combivent.,SOCIAL HISTORY: , Half pack of tobacco x3 years.  No alcohol, occasional marijuana, and no IV drug use.  He lives alone, single and no children.,PHYSICAL EXAMINATION: , Vital signs:  In Emergency Room, temperature 98.2, pulse 83, respirations 20, blood pressure 146/84 and 99% on room air.  General:  This is an alert and oriented African-American male x3 and in no acute distress.  The patient is extremely lethargic and had to be aroused multiple times to answer questions.  Mucous membranes are moist.  HEENT:  Head is normocephalic and atraumatic.  There is no scleral icterus noted.  Pupils are equal, round, and reactive to light.  Extraocular muscles are intact.  Cardiovascular:  Shows a heart rate that is regular with a laterally displaced point of maximum intensity.  There is no murmur, gallop, or rub noted.  Lungs:  Clear to auscultation bilaterally.  No wheeze, rhonchi or rales.  Abdomen:  Soft, nontender and nondistended.  Bowel sounds are present.  Extremities:  Show left forearm with an incision that is well healed from a left AV fistula.  There is a distal thrill palpable and there is some tenderness over the incisional area.  There is no erythema or pus noted.  Other extremities show peripheral pulses present and no edema.,LABORATORY VALUES: , Sodium 139, potassium 3.9, chloride 92, CO2 33, BUN 36, creatinine 9.2, and glucose 131.  Digoxin 0.6, white count is 5.8, hemoglobin 11.7, hematocrit 34.9 and platelets are 252.,IMPRESSION:,1.  Nonfunctional AV fistula.,2.  End-stage renal disease.,3.  Hypertension.,4.  Status post MI.,5.  Clogged PermCath.,PLAN:,1.  Give the patient TPA to the shunt, PermCath in both feet.,2.  To board for Tuesday for shunt repair if needed.,3.  To dialyze as soon as possible.,4.  To review previous operative report.,5.  The patient will be contacted in the morning and told whether to go to dialysis or not.nan