PROGRESS NOTE:
MEDICAL/SURGICAL HISTORY:
HTN, ASCVD, CRF, anemia of CKD, CAD, PAF, massive multinodular
goiter and thyroiditis, CHF history, PPM, CBD stones with sphincterotomy,
duodenal ulcer, partial gastrectomy, splenectomy, several failed arm vascular
access procedures with a functional right Tesio catheter for approximately two
years.
ACTIVE PROBLEM/REVIEW OF SYSTEMS:
For the past two to three days, the patient has been complaining
of some vague paraesthesia of the left face and left arm, as well as, a
sensation of cloudiness or obtundation as evidenced by her son and daughter who
came to the visit today. There was no other specific organ dysfunction and
the patient is actually alert, conversant in her native tongue and able to
calculate.
CURRENT MEDICATIONS:
Metoprolol 50 mg in the a.m. and 25 mg in the p.m., isosorbide 10
mg b.i.d., Cardizem CD 180 mg o.d., Plavix
75 mg o.d., Protonix 40 mg q.o.d., Sinemet 25/100 mg one tablet
t.i.d., Os-Cal with vitamin D q.d., as well as the injectables during dialysis,
which are Zemplar and Epogen.
ALLERGIES:
None known.
PHYSICAL EXAMINATION:
Alert, cooperative woman in no acute distress. Weight is 142
pounds and quite stable. Blood pressure is 150/82. Pulse is 78 and
regular. Her pupils are equal, round and reactive. Her ears are
clear. There was no cerumen buildup. EOMs are intact. Lungs
are clear to auscultation and percussion. The heart is in regular rhythm
at 78 beats per minute. Her Tesio catheter is observed under the right
clavicle. She has no sacral edema and no leg edema. Bilateral leg strength is intact and equal. I did not notice any facial asymmetry.
ASSESSMENT:
A review of laboratory data performed in late November shows
normal hematocrit, hemoglobin, platelet count, and white cell count, normal
electrolyte pattern and blood sugar of 146, calcium and phosphorus, uric acid,
liver function test, total protein, albumin, LDH all within normal limits.
Iron studies showing slightly reduced iron saturation at 18.3% and ferritin
level at 69.
Reviewing her dialysis flow sheet, it appears that the patient has
a very stable dry weight of 141½ pounds without any symptoms suggestive of
CHF. Her blood pressures pre and post dialysis are somewhat erratic.
Her predialysis weight is in the range of 141.0 to 142.6 for the last four
treatments and I suspect that she might be losing dry weight possibly because of
reduced meal volumes or anorexia. Because of the findings on the physical
examination, i.e., the left upper extremity weakness, I am a little suspicious
that she might had a small cerebral event and I have asked her family to obtain
a CT of the brain with contrast if indicated.
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