Multiple Sclerosis

Patient Initials: C.F

Pt. Encounter Number: 1538-20200603-002

Date: 06/03/2020

Age: 69

Sex: F

Allergies: NKDA Advanced Directives: FULL CODE

SUBJECTIVE

CC:

69 years old Hispanic female who presents to the clinic with complaining of Right foot weakness and numbness for nearly 3 weeks and that the foot is difficult to flex. Aching pain reported to bilateral feet and swelling.

HPI: Patient with history of Diabetes Mellitus type II insulin dependent for 10 years. Reported some weakness to right foot and numbness for nearly 3 weeks. She states some tenderness to calf and aching pain to feet. Some swelling reported to bilateral lower extremities. She does report that she has been very thirsty lately and gets up more often at night to urinate. She has attributed these symptoms to the extremely warm weather and drinking more water to keep hydrated. She has gained a total of 20 pounds in the last year.

Current Medications:

Abilify 5 mg tablet SIG: give 1 tablet (5 mg) by oral route once daily             

Amlodipine 10 mg tablet SIG: give 1 tablet (10 mg) by oral route once daily

Benztropine 2 mg tablet SIG: give 1 tablet (2 mg) by oral route 2 times per day

Depakote 500 mg tablet, delayed release SIG: give 1 tablet (500 mg) by oral route 2 times per day

Docusate sodium 100 mg capsule SIG: give 1 capsule (100 mg) by oral route 2 times per day

Enteric Coated Aspirin 81 mg tablet, delayed release SIG: give 1 tablet (81 mg) by oral route once daily

Ferrous sulfate 325 mg (65 mg iron) tablet SIG: give 1 tablet (325 mg) by oral route once daily

Folic acid 1 mg tablet SIG: give 1 tablet (1 mg) by oral route once daily

Glipizide 10 mg tablet SIG: give 1 tablet (10 mg) by oral route 2 times per day

Glucophage 1,000 mg tablet SIG: give 1 tablet (1000 mg) by oral route 2 times per day

Haloperidol 10 mg tablet SIG: give 1 tablet (10 mg) by oral route once daily in the morning

Lipitor 20 mg tablet SIG: give 1 tablet (20 mg) by oral route once daily

Lisinopril 10 mg tablet SIG: give 1 tablet (10 mg) by oral route once daily

Lorazepam 1 mg tablet SIG: give 1 tablet (1 mg) by oral route 2 times per day

Metoprolol tartrate 50 mg tablet SIG: give 1 tablet (50 mg) by oral route 2 times per day with meals

Sertraline 100 mg tablet SIG: give 2 tablets (200 mg) by oral route once daily in the morning

Singulair 10 mg tablet give 1 tablet (10 mg) by oral route once daily in the evening

Toujeo Solostar 300 unit/ml (1.5 ml) subcutaneous insulin pen SIG: inject 65 units by subcutaneous route once daily

PMH

Schizoaffective disorder with major depression.

DM type II insulin dependent.

COPD with heavy smoker

HTN with CVD

Chronic anemia

Hyperlipidemia

Osteoarthritis of multiple sites like cervical and knees

Constipation. GERD

Obese

Sx Hx of cesarean section.

Medication Allergy: NKDA

Medication Intolerances:

None

Chronic Illnesses/Major traumas:

Screening Hx/Immunizations Hx:

Hospitalizations/Surgeries:

Family History:

Type 2 DM present in older brother and maternal grandfather. Both were diagnosed in their late forties. Brother takes both, pills and shots.

Mother alive and well

Father has COPD

Two other siblings alive and well

All 2 children are alive and well

A. Surgery History:

C-section 10 years ago.

Health Maintenance:

Flu vaccine 10/2019

Pneumonia 23 06/2018

PCV 13 11/2019

Menarche at age 12

Last pap smear 6 years ago

G2PAA0

B. Lifestyle Patterns (include spiritual beliefs, behaviors, and traditional practices)

Widowed who lives in a single family home

She is Catholic, has not being able to go to church in 2 months due to COVID-19 virus.

Smokes 1 pack per day. Denies illegal drug uses or alcohol

Does not exercise. Enjoy to watch TV

Social History : The patient has smoked a pack of cigarettes a day for the past 13 years

ROS

General

The patient denies fever, chills, positive weight gained

Cardiovascular

Denies chest pain, palpitations, and difficulty breathing while lying down

Skin

No ulcers, no bruises, no redness

Respiratory

Denies a cough, and wheezing. Reported mild SOB with activity

Eyes

Wears glasses. Denies blurred, double or any loss vision.

Gastrointestinal

Denies nausea, vomiting, abdominal bloating or pain, diarrhea, or food intolerance, but admits occasional episodes of constipation

Ears

External ears normal. Ears without pain, hearing lost, ringing or any discharge

Genitourinary/Gynecological

Has experienced increased frequency and volumes of urination, but denies pain during urination, blood in the urine, or urinary incontinence

Nose/Mouth/Throat

Oral mucosa moist, denies swallowing issues

Musculoskeletal

Reported leg cramp, weakness and numbness to right leg/foot. Reported swelling and aching feet

Breast

Unremarkable

Neurological

Has never had a seizure and denies recent headaches.

Heme/Lymph/Endo

No cervical, clavicular, or posterior auricular lymphadenopathy.

Psychiatric

Denies increase of depression symptoms. No hallucination or suicidal thoughts.

OBJECTIVE

Weight 257.3 LBS BMI 42.1

Temp 97.6

BP 137/81

Height 5’ 5”

Pulse 64

Resp 18

PHYSICAL EXAMINATION

General Appearance

The patient is awake, alert, oriented x3. She is forgetful at times, but usually keeps very oriented. No acute distress noted. The patient is using the walker for ambulation, but sometimes she uses a cane.

Skin

The patient has bilateral psoriasis of elbows.

HEENT

Head: Denies blurred, double or any loss vision. Ears without pain, hearing lost, ringing or any discharge. Nose without bleeding or discharge. Throat: Mouth and throat without any acute disorder. Denies hoarseness, difficulty swallowing and throat or neck pain.

Cardiovascular

S1, S2. Regular rate and rhythm. No murmur. No extra sounds.

Respiratory

No respiratory distress, no wheezing, no use of accessory muscles for respiration. Breath sounds normal. SOB in exertion

Gastrointestinal

Abdomen symmetric, soft, non-tender, and non-distended, bowel sounds presents and normal in all abdominal quadrants, no hepatosplenomegaly, no abdominal bruits, or mass noted. Percussion with normal tympanic and dull areas according to the normal exam. Murphy’s sign negative, no ascites.

Breast

Normal assessment

Genitourinary

No CVA tenderness. No inguinal hernias, no suprapubic pain. Perineum intact without lesion

Musculoskeletal

The patient is able to move all the extremities, ambulate with assistive device, but usually very independent. No tremor noted at this time. Swelling noted to bilateral lower extremities

Neurological

The patient is awake, alert, and oriented x3 as mentioned before. No cranial nerve deficit noted. No neurofocal manifestation found during the physical assessment

Psychiatric

The patient is very cooperative. No anxiety, no suicidal idea. She is very calm.

Laboratory/Test:

Triglycerides 235 (H) A1C 6.9

Urinalysis: WNL

EKG: 64 bpm sinus rhythm:

Special Tests: CBC, CMP, A1C, BNP, Lipid panel, Cardiac Enzymes, U/A, D-DIMER, Thyroid Panel, Liver Panel

EKG, Echocardiogram, Arterial and Venous Doppler, Chest X-ray, ABI

Diagnosis

Primary Diagnosis:

Diabetes Mellitus Type II with Diabetic Polyneuropathy ICD-10: E11.42

Symptoms of diabetes mellitus are those of hyperglycemia. The mild hyperglycemia of early DM is in most of the cases asymptomatic, delaying the diagnosis of the disease for many years. Significant hyperglycemia causes glycosuria that leads to urinary frequency, polyuria, and polydipsia that may progress to orthostatic hypotension and dehydration. Severe patient dehydration makes the patient feel weak, fatigue and even could show symptoms of mental status changes. Disease’s symptoms could come and go as plasma glucose levels fluctuate. Polyphagia may accompany hyperglycemia, but, is not typically the main patient concern. Hyperglycemia is also a possible cause of weight loss, nausea, vomiting, and blurred vision. Hyperglycemia could also predispose the patients to infection such as bacterial or fungal. The disease is usually diagnosed by typical symptoms and signs and confirmed by measurement of plasma glucose. Measurement after eight to twelve hours fast (FPG) or two after ingestion of a concentrated glucose solution. OGTT is more sensitive for diagnosing DM and impaired glucose tolerance, but, is less convenient and reproducible than FPG. It is rarely used routinely, except for diagnosing gestational diabetes and for research purposes as well.

Differential Diagnoses-:

Hansen's Disease (Leprosy) ICD-10 A30.9: Patient can complain of numbness of affected areas of the skin. Also, muscle weakness or paralysis, especially in the hands and feet could be found. Enlarged nerves could be present as well.

Peripheral Artery Disease (PAD) ICD-10 I73.9: The most common symptoms of PAD involving the lower extremities are cramping, pain or tiredness in the leg or hip muscles while walking or climbing stairs. Typically, this pain goes away with rest and returns when you walk again.

Venous Insufficiency ICD-10 I87.2 When your veins have trouble sending blood from your limbs back to the heart, it’s known as venous insufficiency. In this condition, blood doesn’t flow back properly to the heart, causing blood to pool in the veins in your legs. Symptoms of venous insufficiency include: swelling of the legs or ankles, weak legs, aching, pain that gets worse when you stand and gets better when you raise your legs

Heart Failure Unspecified ICD-10 I50.9- Reflected with swelling to lower extremities, weakness and shortness of breath in exertion.

A/P

1. Diabetes mellitus, type 2, insulin-dependent, obesity and polyneuropathy: Will request blood sugar log to monitor blood sugar level for any adjustment needed in the medication, also we will continue with the Toujeo. We will continue monitoring also the hemoglobin A1c for any adjustment needed in the treatment. Oriented the patient to do the foot care to prevent any skin lesion because of the high risk. Also, we will continue with oral medication that she had before which is metformin and Glipizide. We will continue with NCS diet. Encourage portion control. Will add Gabapentin 300 mg capsule SIG: give 1 capsule (300 mg) by oral route 3 times per day

2. Health maintenance. We discuss treatment with patient. We will continue monitoring the chronic disease, lab work to prevent any progression of her disease. We will continue monitoring the patient compliance with the medications, especially with the insulin administration. We will continue monitoring the patient's behavior. We will continue instructing the patient on fall precaution, how to prevent falls. We will continue with no-concentrated-sugar, low-sodium, low-fat, low-cholesterol diet. Will request patient to bring blood sugar log and b/p and weekly weight reading to next visit (in 2 weeks). Educated about smoking cessation .

3. Hypertension, coronary artery disease, hyperlipidemia. - Will continue with current treatment. Will continue using Cardiology as needed for consultation. We will continue providing the patient with Lisinopril, metoprolol and amlodipine and also low sodium diet. So, we will continue monitoring the patient's lipid panel for any adjustment needed in the medications in the meantime. We are going to continue Lipitor 20 mg orally daily for the patient due to the cholesterol is normal and LFT is WNLs. Low sodium, fat/cholesterol diet.

4. Schizoaffective disorder with major depression: We will continue current treatment that patient has. We will order psych evaluation to obtain a base line of the diseases. We will continue monitoring patient behavior for any adjustment needed in medication. We will continue monitoring Depakote level, even when this medication is used as mood stabilizer, just to prevent high dose. We will continue benztropine top prevent side effects of other antipsychotics.

5. EKG, Echocardiogram, ABI and Chest X- ray and Labs – To evaluate Heart function and rhythm- ejection fraction- vascular disease, electrolytes imbalance or deficiencies and check lungs.