neidacaroboone-editngM-88
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Valencia College *
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1611C
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Medicine
Date
Dec 6, 2023
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Uploaded by BrigadierFang12455
Internal Medicine Initial Visit
Patient Name
: Roseanne Erickson
PCP
: Michael Panagides, MD
Date of Exam
: 27 Oct
----
Age/Sex
: 50-year-old female
ID#
: M-88
OUTPATIENT RECORD
: Unavailable.
TIME ALLOTTED FOR VISIT
: 30 minutes.
REASON FOR VISIT
: 50-year-old white female establishing care. Notes an
inability to sleep. She has used amitriptyline for this.
HISTORY OF PRESENT ILLNESS
: The patient states that she has been
plagued by sweating at night. She states that she will go to bed and will be
able to get off to sleep; however, she will awaken with sweating that is
intense. She will sweat through her night clothes and need to get up and
change the night cloths. She then will remain awake. She has found the use
of amitriptyline up to 50 mg ineffective. She is from England and admits that
she will never be able to regard America as her home. She was last back to
England a year ago when her 27-year-old daughter was killed in a nightclub.
Apparently, a date rape drug had been added to her daughter’s drink, and
she had an allergic reaction.The patient does not wake up with headaches,
but she does suffer from these. She describes this as beginning early in her
life. She states that she had parental abuse very early on that eventuated in
a head trauma. These headaches can awaken her, though not usually, and
they are associated with bitemporal pressure to pounding. She prefers
inactivity. The headache will last days without her medications. Years and
years ago she saw neurology for this. She describes the pain as pulsating—
almost like 2 electric wires on either side of her head that are connecting.
There is intense nausea that goes along with this, and she can vomit.The
patient has not attempted any of the newer abortive migraine headache
medicines. She states that she had brought her night sweats to previous
providers' attention, and she was given estrogen replacement therapy;
however, there was no decrease in her night sweats despite an increase to
0.9 mg of Premarin taken each day. This dose was maintained for 4 months.
PAST MEDICAL HISTORY
1. “Emphysema”.
2. Migraines.
Internal Medicine Initial Visit
Patient Name: Roseanne Erickson
Date of Exam: 27 Oct ----
ID#: M-88
Page 2
3.
Nicotine dependence.
4.
Blood clot, left calf, while on birth control pills.
PAST SURGICAL HISTORY
: Hysterectomy 20 years ago without bilateral
salpingo-oophorectomies.
ALLERGIES
: SOFA.
MEDICATIONS
: Fiorinal p.r.n., Proventil p.r.n., baby aspirin each day.
SOCIAL HISTORY
: She lives here in the Miami area. Her husband is a retired
Master Sergeant from the Air Force. He has had recurrence of his Hodgkin
disease after a 17-year remission. They have had 3 children in total. She is
not a drinker, is a smoker.
FAMILY HISTORY
: No migraines, but there is heart disease and diabetes as
well as alcoholism. She did not know her dad well.
REVIEW OF SYSTEMS
: Generally, her weight has gone up over the years.
NEUROLOGIC: She gets headaches as described above. She denies the
description of warning signs with her headaches. She does have a follow-on
washed-out day after resolution of the headache. No seizures or faints.
HEENT: Vision and hearing are stable. ENDOCRINE: No diabetes or thyroid
disease. Heart: No prior heart attack or fast heart rate. PULMONARY: She is
not exercise-limited by her apparent lung disease. She does have wheezing
and shortness of breath that is alleviated with Proventil. GASTROINTESTINAL:
No ulcer disease. GYNECOLOGIC: Normal vaginal deliveries. Approximately 9
years ago she was told that she was entering “the change," as her blood
tests had indicated such.
PHYSICAL EXAMINATION
: Vitals show blood pressure 136/75, pulse 92,
respirations 12, temperature 96.5, height 67 inches, weight 170 pounds. She
is comfortable in the exam chair. Her speech is effortless. NECK: Without
cervical lymphadenopathy, thyromegaly, or nodules. HAIR: She wears her
hair long. It has been dyed blond. She does have gray roots.
Internal Medicine Initial Visit
Patient Name: Roseanne Erickson
Date of Exam: 27 Oct ----
ID#: M-88
Page 3
EYES: Without ejection. HEART: Regular. S1, S2 are within normal limits. I
would appreciate no diastolic or systolic sounds today. EXTREMITIES: Without
cyanosis, clubbing, or edema.
ANCILLARY DATABASE
: 26 October laboratory results show creatinine 1.1
and calcium without albumin 9.4. White blood cells showed a steady
decrease, going upside the normal range with WBC count of 4.2. MCV was
101.7, MCH 34.1, and platelets were 189,000. H&H were 13.9 g and 41.5%.
Labs from 9 years ago: Gonadotropins—follicle stimulating hormone of 147
(0-12 mIU/mL) with luteinizing hormone 43 (0-14 mIU/mL).
ASSESSMENT WITH MEDICAL DECISION-MAKING
1.
Night sweats, an established problem. Additional diagnostics and
therapeutics required. The patient states this condition has worsened over
the last year.
2.
Menopause, an established problem. Additional therapeutics required.
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3.
Leukopenia, new problem. Additional diagnostics and therapeutics
required.
PLAN
1.
We have discussed the role of treat plans in abortive vascular headache
therapy. Since she gets less than 1 a week, we will not start preventive
medicine at this point.
2.
We renewed her Fiorinal but advised her to begin using Zomig 2.5 mg
tablets.
3.
We have prescribed Zomig 2.5, one now and then one 2 hours later at the
first sign of headache.
4.
We recommend that she stop the amitriptyline.
5.
Today we obtained a chest x-ray. (For her peace of mind, I went ahead and
looked at the 2-view.) The x-ray was without active pulmonary disease. I
could appreciate no bony disease. Her heart size was within normal limits,
pulmonary vessels within normal limits. I appreciate no masses and no
adenopathy.
Internal Medicine Initial Visit
Patient Name: Roseanne Erickson
Date of Exam: 27 Oct ----
ID#: M-88
Page 4
6.
We prescribed Ambien 5 mg, 1 p.o. to get to sleep but not to return to
sleep.
7.
We have entered a consult to Hematology, noting the sweating at night,
which seems to meet “night sweats" criteria for myself. It is atypical in
that it has not responded to estrogen replacement therapy and now is
associated with a low white count in a smoker. Smokers can actually have
an increase in their white blood cell count.
8.
At this juncture I would not recommend estrogen replacement therapy for
this patient, only because there is a relative contraindication of ERT in
those who have migraines plus her past history of blood clot on estrogen.
9.
We advised patient to follow up with either myself or Linda Galbraith, FNP,
in approximately 1 month to review her laboratory results and the
response to the initial therapist.
I entered the room at 1405, and I exited at 1440. We spent over half of this
time in counseling and education and the coordination of the patient's care.
____________________________________
Michael Panagides, MD, Internal Medicine
MP:ncb
D: 10/27/----
T: 10/28/----
c:
Linda Galbraith, FNP, Stephen C. Gordon, MD, Hematology/Oncology