SUBJECTIVE: Ms. is a pleasant 70-year-old, white female here today for followup of her difficult-to-control blood pressure, chronic kidney disease, and edema. Her blood pressure has been variable. She notes sometimes athome its a normal of 120s over 70s and other times such as today it is 196-202 systolic. She does endorse being anxious. When I ask her about heranxiety, she notes that certain things will set her off and she internalizes this which in turn drives up her blood pressure. She denies any other new medical concerns or issues today. Her energy is stable. She is eating well, sleeping well, and notes normal body and constitutional function. She denies any medication problems or changes with her regimen. She does note that she is on too many medications without them being effective.
REVIEW OF SYSTEMS: Complete and otherwise negative.
PAST MEDICAL HISTORY: Edema, CKD stage III, hypertension, diabetes type 2, anemia, CHF, Anxiety.
ALLERGIES: MULTIPLE. PLEASE SEE CHART FOR DETAILS.
SOCIAL HISTORY: She is married and lives with her husband in rural Minnesota. She does not use tobacco and only rare alcohol.
OBJECTIVE:Vital signs today include a blood pressure of 196/72, repeat 202/77, heart rate 73, 61 inches tall, 171 pounds.. GENERAL: She is alert, pleasant, interactive, and in no acute distress. HEENT: She is normocephalic with normal hair, ears, and nose. Extraocular movements are intact. Sclerae white, bilaterally. Oropharynx with pink, moist mucosal membranes. Dentition is in good repair. HEART: Is regular rate and rhythm without a murmur or rub. LUNGS: Clear to auscultation bilaterally without wheeze or crackles. ABDOMEN: Is soft, nontender, and nondistended. EXTREMITIES: Upper extremities without edema or cyanosis. Lower extremities have 1+ pitting edema. Her skin is warm, dry, and normal in color. NEUROLOGICAL: She is alert and oriented x3. Cranial nerves III through XII are grossly intact. She has normal to mood, affect, and interaction. Her gait is normal.
LABORATORY DATA:Includes a hemoglobin of 10.6. Her BUN is 47, creatinine is 1.8. Estimated GFR is 28 mL/minute. Her sodium is 133, potassium is 4.7, chloride is 97, bicarbonate is 27. Calcium is 10.3.
IMPRESSION:
1. Acute renal insufficiency.
2. Chronic kidney disease, stage III.
3. Anxiety, very likely a factor in her hypertension.
4. Anemia.
5. Hypertension with poor control on multiple medications.
6. Gout with recent episode.
7. Hyponatremia.
8. Hypercalcemia.
RECOMMENDATIONS:
1. Nebivolol decreased to 20 mg once each day.
2. Clonidine, wean to off over the next 1 week.
3. Telmisartan decreased to 40 mg once each day.
4. Fluoxetine start 10 mg once each day.
5. Alprazolam use 0.25 mg p.o. b.i.d. p.r.n. anxiety.
6. Allopurinol increased to 200 mg once each day.
7. Continue furosemide, however, I will have her take this 20 mg twice each day.
8. Return to clinic in 4-8 weeks.
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