Hypercholesterolemia
Neurological: Negative for dizziness, tingling, tremors, sensory changes, speech changes.
Endocrine/hematologic/allergies: Negative for environmental allergies or polydipsia. Does not bruise or bleed easily.
Psychiatric: Negative for depression, hallucinations and memory loss.
PAST MEDICAL HISTORY:
Diabetes mellitus that was diagnosed 12 years ago with neuropathy. This resolved after gastric bypass surgery, which she had approximately 3 years ago.
Laryngeal cancer
Hypertension
Hypercholesterolemia
Pneumonia
Arthritis
Hypothyroidism
Atrial fibrillation
Acute renal failure
Chronic kidney disease, stage IV – on 07/30/2013 a renal biopsy was completed, which showed focal acute tubular necrosis and patchy tubular atrophy, moderate to severe interstitial fibrosis with patchy acute and chronic interstitial nephritis, normal cellular glomeruli with no white microscopic evidence of a primary glomerulopathy. Baseline creatinine is 1.9.
Peptic ulcer disease
Skin cancer
Anemia
Osteoporosis
PAST SURGICAL HISTORY:
Laparoscopic gastric bypass – 3 years ago
Closure of mesenteric defect.
Radical neck resection on -3 months ago
FAMILY HISTORY:
Mother has diabetes diagnosed at age 55 and high blood pressure. She is deceased.
Father had heart disease diagnosed at age 60. He is deceased.
She had a sister with diabetes, thyroid disease, CKD, on dialysis, with unknown etiology.
SOCIAL HISTORY: She denies any smoking or alcohol use. She denies any drug use.
MEDICATIONS:
Calcitriol 0.5 mcg PO every other day
Vitamin B12 2500 mcg sublingual every Monday and Thursday
Docusate sodium 100 mg PO BID
Fentanyl patch 100 mcg every 72 hours
Gabapentin 800 mg PO BID
Levothyroxine 50 mcg daily
Multivitamin 1 PO Daily
Oxybutynin 5 mg PO BID
Hydrocodone 5/325 1-2 tablets every 6 hours PRN pain
ALLERGIES: SHE IS ALLERGIC TO CIPRO, WHICH CAUSES URTICARIA AND HIVES, CONTRAST DYE, HONEY AND BEE VENOM, ADHESIVE, AND SULFAS, WHICH CAUSE HIVES.
PHYSICAL EXAMINATION:
Vital signs: 38.6, 120, 22, 138/38, 64% on room air. O2 sat of 91 on 4 liters nasal cannula.
Constitutional: She is somnolent. Oriented to person and place. Appears ill and mildly dyspneic.
Head: Normocephalic and atraumatic. Nose: Midline, right and left maxillary and frontal sinuses are nontender bilaterally.
Oropharynx: Clear and moist. No uvula swelling or exudate noted.
Eyes: Conjunctivae, EOM and lids are normal. PERL. Right and left eyes are without drainage or nystagmus. No scleral icterus.
Neck: Normal range of motion and phonation. Neck is supple. No JVD. No tracheal deviation present. No thyromegaly or thyroid nodules. No cervical lymphadenopathy noted bilaterally.
Cardiovascular: rapid rate, S1 and S2 without murmur or gallop. Brachial, radial, dorsalis pedis, and posterior tibial are 2+/4+ bilaterally.
Chest: Respirations are regular and even with mild dyspnea.
Lungs are coarse and with some rales posterior bases.
Abdomen: Soft. Bowel sounds are active, nontender, no masses noted. No hepatosplenomegaly noted. No peritoneal signs.
Musculoskeletal: Full range of motion of the bilateral shoulders, wrists, elbows.
Neurologic: Somnolent. Cranial nerves II-XII are intact.
Skin: Warm and dry.
Psychiatric: Mood and affect are normal. Calm and cooperative. Behavior, judgment is intact.
LABORATORIES AND DIAGNOSTICS:
WBC 7.2, Neutrophil 63%
Creatinine 2.5 mg/dL, BUN 45 mg/dL, Na 144 mEq/L, Potassium 4.4 mEq/L, Total Bilirubin is 0.9 mg/dL, Platelets 100,000
BNP 242 pg/mL
Lactate 1.0 mg/dL
All other labs are unremarkable
Chest x-ray: Right lower lobe infiltrate
EKG: NSR, no ST or T wave changes
