Anamneza

Patient name : Anna Caroll,1951,married,one child.
Presenting complaint:hypotension, sleepiness, reduced appetite, dehydratation ;
HISTORY OF PRESENT ILLNESS: The patient is a female with history of severe

hypertension, diabetes mellitus, cerebrovascular disease, and right-sided hemiplegia. She
was found down at home a week ago. The patient had some problems communicating with
confusing statements and slurred speech. She was more sleepy than usual, and over the
next three to four days, she had been sleeping more throughout the day and eating little,
which is a change from her daily routine. After approximately four to five days, the patient
decided to go to the emergency room for additional evaluation. The patient was admitted to
the emergency room. The patient was however admitted for hypotension. At that time, she
was found to have a blood pressure of approximately 60/40 and dehydration. Hospital stay
was otherwise apparently uncomplicated with the exception of episodes of severe and
almost malignant hypertension, which the patient has had in the past as well as renal
insufficiency, acute on chronic in nature. Renal insufficiency was additionally treated with
hydration and slowly resolved. As for hypertension, it did respond to medication, although,
the patient still continues to run with a systolic blood pressure of 170-190. She has had no
additional sequelae and no new long-term neurological deficits were reported.
PAST MEDICAL HISTORY: Arterial occlusive disease, hypertension, type 2 diabetes.

Right-side hemiplegia approximately one year ago. ;anemia; Numerous abdominal
surgeries.
SOCIAL HISTORY: She is retired. She lives at home. No history of tobacco or alcohol.
FAMILY HISTORY: Negative, except that she had a brother with CVA, as well as mother
who died of an MI and had diabetes. There is no known history of claudication, sickle cell
anemia or any neurological disorders.
REVIEW OF SYSTEMS: She has had right-sided hemiplegia. She has denied any
additional signs or symptoms of ongoing CVA or TIAs. She denies amaurosis fugax. No
auditory or visual changes. She denies any hair, nail or skin changes, weight changes, heat
or cold intolerance. No bladder or bowel changes, chest pain, shortness of breath or cough.
No edema or erythema of her extremities.
PHYSICAL EXAMINATION:
GENERAL: The patient is a well-developed, well-nourished, pleasant, in no apparent
distress. She is afebrile.
VITAL SIGNS: Stable. Blood pressure 180/80, pulse 78 and regular, respiratory rate 18-22.
SKIN: Warm and dry with good color.She has numerous surgical incisions, well healed.
There is no rash. No tissue breakdown, bleeding or bruising.
HEENT No complaints of headache change in vision, nose or ear problems, or sore throat.
NECK: Soft and supple. No gross thyromegaly. No anterior/posterior cervical adenopathy.

Range of motion appears normal and unremarkable.
HEART: Regular rate and rhythm.
CHEST: Fairly clear. She has faint expiratory wheezes, particularly on the left compared to
the right. Right side has fair breath sounds.Equal chest wall expansion.
ABDOMEN: Obese.Have some surgical scars. Bowel sounds are normal in quality and
intensity in all areas.
PELVIC: Normal-appearing female.
EXTREMITIES: No cyanosis. Trace edema, right side worse than left. Peripheral pulses in
the femoral, popliteal, anterior tibial, dorsalis pedis,brachial, and radial areas are normal.
NEUROLOGICAL: She is mildly hyperreflexive. Sensorium is intact in her upper and lower
extremities. She is aware of the month, date and time, as well as where she is presently
located, also aware of the president and season.
ASSESSMENT AND PLAN:

1. Mental status change, etiology unknown. CT scan was performed, results are not
available at this time. Possibly secondary to hypertensive crisis/onset of cerebrovascular
disease, new/transient ischemic attack. We will continue to treat blood pressure as well as
blood sugars as necessary. I cannot appreciate any type of infection causing these
reactions. However, I may consider followup blood cultures or follow up any additional tests
obtained.
2. History of cerebrovascular accident/transient ischemic attack. The patient has a history
of at least four in the past with residual right hemiplegia up until one year ago. At home,
she states she is on aspirin only but was on Coumadin sometime in the past, but this
stopped a number of years ago. I do not have any report finding consistent with lower
extremity deep venous thrombosis or cancer or other possible etiologies for embolic
ischemic events. I may consider obtaining old medical records for evaluation of etiology. I
placed the patient on Fragmin 5000 subcutaneous daily as well as continuing the aspirin
daily.
3. Diabetes mellitus. Fingerstick blood sugars q.a.c. and h.s. Sliding scale insulin will be
written for as well as routine medication. Continue to follow closely.
4. Hypertension. We will continue with clonidine as recommended and additional Lopressor
and may consider nitroglycerin patch on a p.r.n. basis for elevated blood pressures.
Consider obtaining electrocardiogram for baseline. Labs results, CBC, will be obtained.
5. Chronic renal insufficiency. I will obtain BUN and creatinine and continue to follow.
PT/OT and speech consultations have been requested.

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Patient name : Anna Caroll,1951,married,one child.

Presenting complaint:hypotension, sleepiness, reduced appetite, dehydratation ;

HISTORY OF PRESENT ILLNESS: The patient is a female with history of severe

PAST MEDICAL HISTORY: Arterial occlusive disease, hypertension, type 2 diabetes.

NECK: Soft and supple. No gross thyromegaly. No anterior/posterior cervical adenopathy.

PELVIC: Normal-appearing female.

ASSESSMENT AND PLAN:

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