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PATIENT PRESENTATION

Chief Complaint

“I feel dizzy and out of it.”

History of Present Illness

WL is an 82-year-old Caucasian female brought to the emergency department by her daughter after finding her mother to be very lethargic and weak. Patient states that she has been feeling tired and out of it all the time lately, so she stays in bed a lot. When she tried to get up from the bed, she felt like she was going to faint and had to sit back down for a minute before trying to get up again. Upon questioning, she also states that she fell a couple of times in the past month but luckily didn’t break anything, so she did not come to the emergency room. She states that she has chronic back pain but currently she is only experiencing stiffness and no pain.

Past Medical History

Hypertension (HTN)

Heart failure with reduced ejection fraction (HFrEF)

Generalized anxiety disorder

Type 2 diabetes mellitus (DM)

Neuropathy

Chronic back pain

Chronic kidney disease (CKD)

Seasonal allergies

Surgical History

Appendectomy, cesarean section

Family History

Father: had CAD and passed away from a myocardial infarction at age 50

Mother: has type 2 DM and hypothyroidism

Social History

Since her husband passed away 4 years ago, she has been living alone.

Son and daughter live about 1.5 hours away and visit their mother every other week to check in on her.

Drinks alcohol occasionally (3–4 times per month).

Does not smoke or use illicit drugs.

Immunization

All immunizations up to date

Insurance

Medicare

Allergies

No known drug allergies

Home Medications

  • Sacubitril/valsartan 97/103 mg PO bid (started 2 years ago)

  • Carvedilol 25 mg PO bid (started 8 years ago)

  • Spironolactone 50 mg PO daily (started 5 years ago)

  • Furosemide 40 mg PO daily (started 8 years ago)

  • Clonidine 0.2 mg PO bid (started 20 years ago)

  • Gabapentin 300 mg PO tid (started 15 years ago)

  • Hydrocodone/acetaminophen 10/325 mg PO q6h PRN pain (started 20 years ago, takes about 1 to 2 times daily)

  • Trazodone 100 mg qHS (started 6 months ago)

  • Alprazolam 1 mg PO tid (started 30 years ago at a lower dose)

  • Diphenhydramine 25 mg PO ...

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