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Unofficial concept by Hafsa Usmani · Not affiliated with Akasa · Synthetic charts only, no patient data

enc-18 · 68M · 2026-09-08 to 2026-09-11 · 6 documents

AKI vs. baseline CKD, consultant disagrees

The hospitalist calls it acute kidney injury, but the kidney specialist says the creatinine is just the patient's usual level, so the attending must be asked to resolve the conflict.

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The chart

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ED note

J. Whitcomb, MD (Emergency Medicine) · Provider · 2026-09-08 15:02

CC: nausea, poor PO intake, lightheaded. HPI: 68 y/o M with T2DM on insulin, HTN, CKD, HLD, OSA presents with 3 days of nausea and decreased PO intake after a "stomach bug" at home (grandchildren sick). 2 episodes of emesis day 1, none since. No diarrhea x 24 h. Lightheaded on standing this AM. Continued lisinopril and HCTZ at home. Vitals: T 36.8, HR 98, BP 112/66 (orthostatic drop to 96/60 standing), RR 16, SpO2 97% RA. Exam: Dry mucous membranes. Abd soft, mild diffuse tenderness, no rebound. Lungs clear. Labs: Na 137, K 4.6, Cl 101, HCO3 23, BUN 34, Cr 1.5, glucose 211. WBC 8.1. Lipase nl. UA: SG 1.025, trace protein, no blood. ED course: 1 L NS bolus, ondansetron 4 mg IV. Impression: Dehydration, nausea, elevated Cr. Admit to hospitalist.

H&P

A. Lindqvist, MD (Hospital Medicine) · Provider · 2026-09-08 18:30

HISTORY AND PHYSICAL HPI: 68M with T2DM (insulin), HTN, CKD 3a, HLD, OSA on CPAP, presenting with 3 days nausea/poor PO intake after viral GI illness, now lightheaded with orthostasis. Cr 1.5 today; last value I can find in our system is 1.1 (06/2022). PMH: T2DM with diabetic nephropathy, HTN, CKD 3a, HLD, OSA. Meds: insulin glargine 24 u qHS, lispro SSI, lisinopril 20 mg daily, HCTZ 25 mg daily, atorvastatin 40 mg, CPAP nightly. Exam: Tired-appearing, A&Ox3. Dry MM. RRR. Lungs CTAB. Abd soft. No edema. ASSESSMENT/PLAN: 1. AKI on CKD 3a - Cr 1.5 from 1.1 (2022), likely prerenal from volume depletion + ACEi/thiazide. Hold lisinopril and HCTZ. IVF NS 100 mL/h. Strict I/O. Renal US if not improving. Nephrology consult for AKI on CKD. 2. Dehydration due to viral gastroenteritis, resolving - IVF, antiemetics PRN, advance diet. 3. T2DM with diabetic CKD, on insulin - reduce glargine to 16 u while PO poor, SSI. 4. HTN - holding antihypertensives as above; BP soft. 5. HLD - atorvastatin. 6. OSA - CPAP qHS. DVT ppx: heparin SQ. Full code.

Consult

P. Raghunathan, MD (Nephrology) · Consultant · 2026-09-09 11:15

NEPHROLOGY CONSULTATION Reason: "AKI on CKD 3a." HPI: As per H&P. Reviewed outside records from his nephrologist (Dr. Ferreira, Valley Kidney Associates): creatinine 1.4 (03/2025), 1.6 (11/2025), 1.5 (05/2026); eGFR 46-54. Followed for CKD 3a due to diabetic nephropathy with contribution from hypertension. UACR 180 mg/g (05/2026). Today: Cr 1.5 -> 1.5 (AM). UOP 1.6 L/24 h. UA bland, no casts. Exam: Euvolemic after IVF. No edema. No rub. ASSESSMENT: 1. No AKI. Creatinine 1.5 is at his established baseline of 1.4-1.6; the 2022 value of 1.1 predates his CKD progression and is not an appropriate comparator. KDIGO criteria for AKI not met. 2. CKD stage 3a due to diabetic nephropathy and HTN, stable. 3. Mild volume depletion from GI losses, corrected. RECOMMENDATIONS: - Stop IVF today, encourage PO. - Resume lisinopril at discharge once taking PO well; would hold HCTZ until seen in clinic. - No renal imaging needed. - Follow up with Dr. Ferreira in 4-6 weeks. We will sign off; call with questions.

Lab summary

Clinical Laboratory · Lab · 2026-09-10 06:20

Creatinine trend: 09/08 15:00 1.5; 09/09 05:30 1.5; 09/10 05:40 1.4. BUN: 34 -> 25 -> 19. K 4.6 -> 4.3 -> 4.2. HCO3 23 -> 24 -> 25. Glucose (fingerstick) range 132-244. Outside results scanned to chart 09/09: Cr 1.4 (03/2025), 1.6 (11/2025), 1.5 (05/2026).

Progress note

A. Lindqvist, MD (Hospital Medicine) · Provider · 2026-09-10 09:40

S: Nausea resolved, tolerating regular diet. No lightheadedness walking in hall. O: T 36.7, HR 76, BP 134/80, orthostatics negative. Cr 1.4, BUN 19. A/P: 1. AKI on CKD 3a - Cr 1.5 -> 1.4, improving with hydration. Nephrology input appreciated. IVF stopped. 2. Dehydration due to viral gastroenteritis - resolved. 3. T2DM with diabetic CKD on insulin - BG 130-240s, resume home glargine 24 u tonight. 4. HTN - BP up; resume lisinopril tomorrow AM, continue holding HCTZ. 5. HLD, OSA - stable. Plan d/c home tomorrow.

Discharge summary

A. Lindqvist, MD (Hospital Medicine) · Provider · 2026-09-11 10:50

DISCHARGE SUMMARY Admit 09/08/2026 - Discharge 09/11/2026. Home, self-care. Principal diagnosis: Acute kidney injury on CKD stage 3a, prerenal, resolved. Secondary diagnoses: Dehydration due to viral gastroenteritis. Type 2 diabetes mellitus with diabetic CKD, on insulin. Hypertension. Hyperlipidemia. Obstructive sleep apnea. Hospital course: Admitted with 3 days of nausea/poor PO intake and orthostasis, Cr 1.5. Treated as prerenal AKI on CKD 3a with IVF and holding ACEi/thiazide. Cr 1.4 at discharge. Seen by nephrology. Tolerating diet. Discharge meds: resume lisinopril 20 mg daily; HOLD HCTZ until nephrology follow-up; insulin glargine 24 u qHS; atorvastatin 40 mg. Follow-up: PCP 1 week with BMP; Dr. Ferreira (nephrology) 4-6 weeks.

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