DATE OF CONSULTATION: MM/DD/YYYY
REASON FOR CONSULTATION: Medical management.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old Hispanic female admitted with a pregnancy. According to the patient, she was diagnosed last week with urine drug screen. The patient says normally she takes Lortab, Lyrica and Neurontin for her diabetic neuropathy. When she went to the clinic to get her medication refilled, she had a urine pregnancy screen done, which was positive, so the patient was referred here. The patient is approximately 9 weeks’ pregnant. The patient denies any nausea or vomiting. The patient says she is followed for her hypertension, and she is also followed for her diabetes, and she has been taking her Diovan, lisinopril, Neurontin, Lyrica, and Lantus.
PAST MEDICAL HISTORY:
1. Recurrent hospital admission for DKA.
2. Insulin-dependent diabetes mellitus.
3. Hypertension.
PAST SURGICAL HISTORY: Negative.
ALLERGIES: No known drug allergies.
CURRENT MEDICATIONS:
1. Lantus 50 units subcu at bedtime.
2. Humalog sliding scale.
3. Lisinopril 5 mg p.o. daily.
4. Neurontin 800 mg p.o. 3 times daily.
5. Lyrica 100 mg p.o. b.i.d.
6. Diovan 160 mg p.o. daily.
7. She is on Metanx and iron supplement as well.
SOCIAL HISTORY: The patient lives with her sister and niece. The patient does not smoke. Denies any drug abuse. Denies any alcohol abuse. Her primary care provider is Dr. John Doe.
FAMILY HISTORY: The patient says she was adopted and does not know much about her parents’ medical history.
REVIEW OF SYSTEMS:
CONSTITUTIONAL: Complaining of generalized weakness. No fever. No dizziness. Complaining of weight gain.
HEENT: No nasal congestion, rhinorrhea or epistaxis.
CARDIOVASCULAR: Denies any palpitations, chest pain, dyspnea, orthopnea, PND.
RESPIRATORY: Denies any shortness of breath. No cough or hemoptysis.
GASTROINTESTINAL: Denies any abdominal pain, nausea or vomiting, diarrhea, constipation.
GENITOURINARY: No dysuria, frequency or urgency and hematuria.
MUSCULOSKELETAL: Denies any back pain, neck pain or calf pain.
DERMATOLOGY: Denies any rash, discoloration.
NEUROLOGICAL: Denies any headache, paresthesias, weakness, no seizure, no vision changes. No focal sensory and motor deficit.
ENDOCRINE: Complaining of polyuria, polydipsia.
PHYSICAL EXAMINATION:
GENERAL: No acute distress, alert and oriented to time, place, and person.
VITAL SIGNS: Temperature is 97.8, pulse 100, respirations 20, and blood pressure 118/78. Admission weight is 74 kg.
HEENT: Moist mucous membranes, anicteric sclerae.
NECK: Supple, no jugular venous distention or carotid bruits noted.
HEART: S1, S2 audible, non-reproducible chest pain.
LUNGS: Clear breath sounds bilaterally. No wheezing or rales.
ABDOMEN: The patient is pregnant. Uterine size is approximately 9 weeks. No organomegaly. Normoactive bowel sounds.
GENITOURINARY: Deferred.
EXTREMITIES: No clubbing, cyanosis or edema.
NEUROLOGICAL: Cranial nerves II through XII intact. No sensory or motor deficits noted.
DIAGNOSTIC WORKUP: The patient has obstetric ultrasound done, which shows single living intrauterine fetus. Estimated gestational age of 7 weeks and 6 days. Fetal cardiac activity is noticed. Heart rate is approximately 62 beats per minute. A 2.6 cm cyst in left ovary is also noticed. This is likely a corpus luteal cyst.
LABORATORY WORKUP: Sodium 136, potassium 4.2, chloride 102, CO2 of 28, glucose 270. BUN 11, creatinine 0.4. Alkaline phosphatase 88, total bilirubin 0.3. AST 14, ALT 12. Hemoglobin A1c 10.8. WBC 10, hemoglobin 11.6, hematocrit 35.4, and platelets 378.
CLINICAL IMPRESSION:
1. Intrauterine pregnancy.
2. Insulin-dependent diabetes mellitus.
3. Hypertension.
RECOMMENDATIONS:
1. This is a well-known patient with recurrent hospital admission in the past with DKA.
2. At present, the patient is admitted to the OB/GYN service for further evaluation.
3. We will start the patient on gentle IV fluid hydration, serum ketones in the morning, check the patient’s electrolyte. Check the patient’s TSH. Accu-Chek before meals and regular insulin sliding scale.
4. Start the patient on Lopressor 25 mg p.o. b.i.d. and hold if her systolic blood pressure is less than 100.
5. Urine drug screen.
6. Start the patient on prenatal vitamins as well.
7. Considering the patient has been taking Diovan, lisinopril, Lyrica and Neurontin for a long period of time, at present, the patient’s pregnancy is extremely high risk from the teratogenic effect of these medications. We will advise to discontinue the patient’s Neurontin, Lyrica, Diovan and lisinopril.
8. Continue to monitor the patient in the hospital.
9. The patient has been explained her findings, and at present, she will need very close monitoring of her insulin and tight glycemic control, and we will continue to follow this patient during the hospital course for her diabetes and hypertension.
