DATE OF SERVICE: MM/DD/YYYY
HISTORY OF PRESENT ILLNESS: The patient is a very pleasant (XX)-year-old female who comes in today for followup evaluation for subacute aches and night sweats. The patient was quite anxious about these issues when she established care with us earlier this month. Since then, we have done extensive lab work as well as had her visit with Rheumatology. We reviewed her lab work today as well as rheumatologist’s diagnosis of fibromyalgia.
The patient’s lab work showed that her ferritin is still low, although not as low as previously. Her vitamin D levels were insufficient, requiring repletion, but all other labs including serologies as well as a chest x-ray were otherwise normal with no explanation for her symptoms. The patient at this point is embarking on therapy for fibromyalgia, which she feels will improve her symptoms.
The patient remains concerned about her anemia and is planning to follow up with Dr. John Doe regarding that.
The patient has also started to decrease her Effexor, which she thinks may be causing her night sweats. She was concerned about interactions between that and tramadol. She is currently taking 75 mg a day, down from 150 a day.
The patient does note that she takes Nexium nightly and has for the last 1-1/2 years. Prior to that, she used ranitidine for acid reflux. Without this, she had nausea and vomiting from acid reflux. She is currently taking iron tablets despite the antacid therapy.
PAST MEDICAL HISTORY: Alpha thalassemia trait, benign essential hypertension, migraine, esophageal reflux, Raynaud’s syndrome, fibromyalgia, hiatal hernia, hyperlipidemia, iron deficiency, and irritable bowel syndrome.
CURRENT MEDICATIONS: Cyclobenzaprine 10 mg half to two tablets p.o. at bedtime, Effexor 75 mg p.o. daily, Maxalt 10 mg p.r.n., Nexium 40 mg p.o. daily, tramadol 50 mg one to two tablets p.r.n., and vitamin D repletion.
ASSESSMENT AND PLAN:
1. Night sweats. The patient’s night sweats could in fact be caused by SSRIs. We will switch her to Wellbutrin. We have given her instructions on how to taper off Effexor and increase Wellbutrin.
2. Muscle aches. The patient is currently embarking on therapy with rheumatologist with regard to this.
3. Iron-deficiency anemia. It is not clear to us why the patient’s ferritin does not remain repleted. We discussed appropriate iron therapy including taking vitamin C with her iron, given that she is on an antacid therapy. She will follow up with Dr. John Doe as noted. We are also going to set up a gastrointestinal consult, given her longstanding acid reflux as well as a concern for iron-deficiency anemia. A colonoscopy was negative in the past; however, we would like her to touch base with one of the gastrointestinal doctors.
4. Vitamin D deficiency. We will order 50,000 units a week for 8 weeks.
