University of Alabama at BirminghamSchool of Medicine

Pharmacology Case #1a

MS. N.MEDICAL RECORD # 00000009/6/02

Ms. N is a 72 y.o. lady with the following medical problems:

  1. Hypertension
  2. Hyperlipidemia
  3. Diabetes mellitus (type 2), diet-controlled
  4. Chronic obstructive pulmonary disease
  5. Congestive heart failure
  6. Non-ulcer dyspepsia
  7. Insomnia
  8. Glaucoma
  9. Osteoarthritis
  10. History of tobacco abuse

Current Medications

  1. Hydrocholothiazide 25 mg qam.
  2. Long-acting nifedipine 30 mg qd.
  3. Atorvastatin 10 mg qhs.
  4. Theophylline SR 400 mg bid
  5. Combivent (albuterol and ipatropium) metered dose inhaler 2 puffs qid.
  6. Prednisone 10 mg qam.
  7. Ranitidine 150 mg qhs.
  8. Pilocarpine HCL eye drops 4% 1 gtt ou qid.
  9. Timolol eye drop 0.5% 1 gtt ou bid.
  10. Mylanta 1 tablespoon before meals as needed for heartburn.
  11. Diazepam 5 mg hs as needed for sleep.

Interval History

Mrs. N is being seen today because of a fall 2 days ago. The patient states that she was walking across her living room when she slipped on a throw rug, fell to the ground and sustained an injury to her right ankle. There was no associated chest pain, palpitations, worsening of her baseline shortness of breath, headache, double vision, difficulty speaking, or loss of consciousness, and Ms. N did not sustain an injury to her head. On Review of Systems, she reports lightheadedness on standing; generalized weakness; urinary frequency, urgency and dysuria (i.e., burning on urination); polyuria and polydipsia, and blurred vision for the last week. She does not check her blood sugars at home.

Physical Examination

The patient is a well-dressed, well-appearing woman looking less than her stated age.

BP 110/60 P 80, sitting; BP 90/62 P 100, standing

T 101o, Wt 126 lbs (-6 lbs since the last appointment on 7/7/02)

Skin: Reduced skin turgor w/ dry mucus membranes.

HEENT: Normocephalic, non-traumatic. Eyes and ears are unremarkable. Mouth was edentulous.

Neck: Supple with flat neck veins.

Chest: Clear to percussion and auscultation with diminished breath sounds throughout. Tender to percussion at the right costovertebral angle.

Heart: Lateral point of maximum impulse with a soft S1 and a physiologically split S2.

Abdomen: Benign.

Extremities: The right ankle is mildly swollen and tender medially, but is without deformity. Pulses are intact.

Neurological: Proximal lower extremity weakness is noted bilaterally with decreased sensation to pin and light touch distally and absent ankle jerks.

Laboratory

Finger stick glucose = 350 mg/dl

Electrocardiogram was without abnormality

Urine appeared cloudy w/ 2+ glycosuria, 1+ proteinuria, nitrite +, 1+ hematuria noted on dipstick

Supported by a grant from the Association of American Medical Colleges and the John A. Hartford Foundation.

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