HISTORY
The patient is a 43-year-old female who carries a diagnosis
of scleroderma, insulin-dependent diabetes, hypertension. Her hypertension has been accelerated lately
secondary to vomiting, unable to keep down meds. She has been on nifedipine 30 milligrams a
day and Toprol-XL 50 milligrams a day.
She has been throwing up daily and usually seeing her nifedipine in
there. She does not know if she is
getting her prednisone down either, but her swelling has gotten progressively
worse. She is chronically fatigued and
is having difficulty doing anything. Her
concern now is her blood pressure is so high.
She went to North Baldwin ER Friday evening or Friday and was worked up
for accelerated hypertension. They gave
her some medicine for headache, gave her 40 mEq of p.o. potassium even though
she is having some nausea and vomiting.
She said she went home and she threw all the pills back up. She just has not felt good since, and she has
been trying to take her medicine as prescribed.
Her sugar has been okay, but she has not been eating much because it is
difficult to swallow. I asked her if the
food gets stuck in any particular position, and she said she is not sure; it
just does not feel like it goes down right.
This probably goes along with her scleroderma.
PAST MEDICAL HISTORY
She has been a diabetic since 1991, has been on insulin for
approximately 10 years. She says the
diagnosis of scleroderma has been worked up by Dr. Sullivan and she has had
dyspnea secondary to scleroderma or just multifactorial that has been worked up
by Dr. Griffin. She also has GERD.
FAMILY HISTORY
At this time is noncontributory.
SOCIAL HISTORY
She does not smoke.
She has a 2-year-old child and she is single. She is disabled.
OBJECTIVE
GENERAL/VITAL SIGNS/HEENT:
When I see patient, her blood pressure is 200/120, her pulse is
100. She is very anxious. She is worried about having a stroke and just
this inability to swallow. She has
depigmentation of a lot of her skin. She
is starting to get some tightening of the fingers as well and the skin
general. Face is very prominent. I cannot get a pulse oximetry on our machine
here in the office. She does on
fingernail polish; I just cannot pick it up.
She does have Raynaud phenomenon as well with her scleroderma.
NECK: Tight.
CHEST: She has
bilateral breath sounds, which sound pretty clear to me. I do not hear any wheezes, any crackles.
CARDIAC: Revealed a
tachycardic rhythm right at 100 with a soft 1/6 murmur at the left sternal
border.
ABDOMEN: Benign.
EXTREMITIES: She is
not edematous.
DATA
These are labs from North Baldwin: Her potassium is 2.9 and she had some other
mild electrolyte abnormalities; glucose and stuff, which would be expected, was
190, but it was a random glucose.
ASSESSMENT
I talked to her about her swallowing and discussed with Dr.
Sullivan, her rheumatologist, who said, you know she is probably going to need
to be dilated. So he talked with Dr.
Ives and he is going to set up tomorrow, but with a potassium of 2.9, this lady
needs to go into the hospital to get this corrected before they do any invasive
procedures, and he is in agreement.
ADMISSION DIAGNOSES
1. Accelerated
hypertension secondary to inability to keep down medications.
2. Nausea
and vomiting secondary to scleroderma.
3. Scleroderma,
moderate.
4. Dyspnea;
has been worked up with Dr. Griffin. He
evidently did a recent high resolution CT scan; I do not have the result back
yet.
5. Insulin-dependent
diabetes mellitus.
PLAN
Will admit to the hospital.
Will correct her potassium as needed.
Will consult Dr. Sullivan and Dr. Ives.
She is probably going to need at least and EGD and probably
dilatation. I put her on some p.r.n.
clonidine. I did get her to take an AZOR
which is 5 of Norvasc and 20 of Benicar here in the office, and she was able to
keep this down, but it is a very tiny pill.
She also will remain on her Toprol.
Will get an EKG. Will get cardiac
enzymes. She had an echo that was
reported as normal through Drs. Griffin and Sullivan's office, but I do not
have that official report. Will get Dr.
Sullivan to consult so they can help.
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