IM/Hospitalist Progress Note

Subjective:
Clinical Course:
Ms. Julia is a patient with a past medical history of fibromyalgia, chronic kidney disease, spine pathology resulting in difficulty standing for prolonged periods, hyperlipidemia, anxiety, and depression. She presents for follow-up of her chronic medical conditions. She reports adherence to a plant-based diet, avoidance of meat and fried foods, daily consumption of blueberries, use of turmeric supplements, and high water intake. She has not initiated the previously prescribed cholesterol-lowering medication, preferring to attempt dietary management first. She reports reducing her Midodrine dosage to once daily due to cooler weather. She has a history of unsuccessful trials of Gabapentin and Duloxetine for fibromyalgia. She expresses concern regarding financial support due to inability to work since age 40 and potential cessation of alimony payments, and is considering applying for Supplemental Security Income based on her medical conditions. She is currently under psychiatric care for anxiety and depression.

Today's Updates:
February 13, 2026:
Ms. Julia presents for follow-up of her chronic medical conditions. She reports adherence to a plant-based diet, avoidance of meat and fried foods, daily consumption of blueberries, use of turmeric supplements, and high water intake. She has not initiated the previously prescribed cholesterol-lowering medication, preferring to attempt dietary management first. She reports reducing her Midodrine dosage to once daily due to cooler weather. All rheumatological tests came back negative, including tests for lupus, mixed connective tissue disorder, Sjögren's, and scleroderma. Inflammatory markers are low, with erythrocyte sedimentation rate at 8 and C-reactive protein less than 1. Kidney function has slightly improved, with glomerular filtration rate increasing from 61 to 64. Blood pressure is measured at 126/84 mmHg. Ms. Julia expresses concern regarding financial support due to inability to work and potential cessation of alimony payments, and is considering applying for Supplemental Security Income based on her medical conditions. The physician completed a jury duty exemption form based on her fibromyalgia and spine pathology. Education was provided regarding dietary management of hyperlipidemia, the plan for tapering Midodrine, and documentation to support her application for assistance.

Review of Systems (ROS):
Ms. Julia denies symptoms suggestive of lupus, mixed connective tissue disorder, Sjögren's syndrome, or scleroderma. She does not report new musculoskeletal, renal, or systemic symptoms. No additional review of systems findings are provided.

Chief Complaint:
Follow-up for fibromyalgia, chronic kidney disease, spine pathology, hyperlipidemia, anxiety and depression.

Objective:
Physical Exam:
Blood pressure is measured at 126/84 mmHg. No further physical examination findings are documented.

Assessment and Plan:
Ms. Julia is a patient with a history of fibromyalgia, chronic kidney disease, spine pathology, hyperlipidemia, anxiety, and depression who presents for routine follow-up. She is adherent to dietary modifications and has not initiated statin therapy. Laboratory evaluation reveals negative rheumatological tests, low inflammatory markers, and stable to improved renal function.

1. Fibromyalgia (M79.7)
- Assessment: Persistent symptoms with prior unsuccessful trials of Gabapentin and Duloxetine. Severe enough to warrant jury duty exemption and consideration for disability support.
- Plan: Documentation of severity and prior treatment failures provided to support application for Supplemental Security Income.

2. Chronic kidney disease (N18)
- Assessment: Stable with slight improvement in glomerular filtration rate from 61 to 64.
- Plan: Continue monitoring renal function; repeat laboratory evaluation in two months.

3. Hyperlipidemia (E78.49)
- Assessment: Patient has not initiated pharmacologic therapy, opting for dietary management. Cholesterol levels to be reassessed.
- Plan: Continue plant-based diet and supplements; recheck lipid panel in two months.

4. Orthostatic hypotension (I95.1) (Midodrine use)
- Assessment: Reduced Midodrine to once daily due to cooler weather and stable blood pressure.
- Plan: Taper Midodrine over the next month as instructed.

5. Anxiety and depression (F41)
- Assessment: Managed by psychiatrist.
- Plan: Continue psychiatric care.

Disposition: