Virtual Thrombosis follow up

Subjective:
Chief Complaint:
Follow-up for fibromyalgia, chronic kidney disease and hyperlipidemia.

History of Present Illness:
Ms. Julia Carter reports adherence to daily blood pressure monitoring at home. She has not initiated the previously prescribed cholesterol-lowering medication, preferring to attempt dietary and lifestyle modifications first. She describes a plant-based diet, high intake of blueberries, avoidance of meat and fried foods, and use of turmeric supplements. She also reports daily consumption of large volumes of water and cultivation of organic vegetables in a hydroponic garden. Ms. Carter has reduced her Midodrine dosage to once daily due to cooler weather. She denies any new symptoms related to her chronic kidney disease or fibromyalgia. There are no reports of recent hospitalizations, acute exacerbations, or new symptoms. Recent laboratory results from April 7th indicate negative rheumatological markers, low inflammatory markers, and stable to slightly improved renal function.

Past Medical History:
Ms. Carter has a history of chronic kidney disease with a recent improvement in glomerular filtration rate from 61 to 64. She has severe fibromyalgia, previously treated with Gabapentin and Duloxetine without significant benefit. She is under psychiatric care for anxiety and depression. She has been managing her hyperlipidemia through dietary and lifestyle modifications, including a plant-based diet, high intake of blueberries, avoidance of meat and fried foods, and the use of turmeric supplements. She has been taking Midodrine but has reduced the dosage to once daily due to cooler weather. She monitors her blood pressure daily and has reported good compliance.

Social History:
Ms. Carter has not worked since the age of 40. She maintains a hydroponic garden where she grows organic vegetables and consumes a healthy diet.

The Review of Systems:
General: No new symptoms reported related to chronic kidney disease or fibromyalgia.
Psychological: Expresses concern about financial support and potential loss of alimony payments.

Current Medications:
Midodrine, reduced to once daily. Turmeric supplements. No cholesterol-lowering medication initiated as the patient prefers dietary and lifestyle modifications.

Objective:
Physical Examination:
General: The patient appears well-nourished and in no acute distress.
Vital Signs: Blood pressure is 126/84 mmHg.
Physical examination was deferred due to the telehealth nature of this consultation.

Vital Signs:
Blood pressure: 126/84 mmHg.

Investigations:
All rheumatological tests came back negative, including tests for lupus, mixed connective tissue disorder, Sjögren's, and scleroderma. Inflammatory markers are low, with ESR at 8 and CRP less than 1. Kidney function has slightly improved with a GFR increase from 61 to 64.

Assessment:
Impression:
Ms. Carter presents for follow-up of chronic medical conditions, including fibromyalgia, chronic kidney disease, and hyperlipidemia. Her blood pressure is well-controlled, and her kidney function has shown slight improvement. She is managing hyperlipidemia through dietary and lifestyle modifications and has reduced her Midodrine dosage.

Problem:
1. Fibromyalgia (729.1)
2. Chronic kidney disease, stage unspecified (585.9)
3. Hyperlipidemia, unspecified (272.4)
4. Anxiety disorder, unspecified (300.00)
5. Depressive disorder, unspecified (311)

Plan:
I completed and signed the jury duty exemption form for Ms. Carter, citing her fibromyalgia and spine issues as the basis for exemption. I recommended tapering off Midodrine completely over the next month. The tapering plan involves reducing the dosage to every other day for two weeks, then every third day for two weeks, and subsequently discontinuing the medication.

I advised her to continue with dietary and lifestyle modifications to manage her hyperlipidemia for the next six months. Additionally, I recommended monitoring her lipid panel and kidney function in two months to assess progress and ensure no adverse effects.

To support her SSI application, I documented her severe fibromyalgia and noted the ineffectiveness of previous treatments with Gabapentin and Duloxetine. Lastly, I acknowledged that her anxiety and depression are being managed by her psychiatrist.