Rasmeet Chhabra

ID: 11109840

2 March 2016
Windsor U SOM

39 y/o man presents with disorientation, confusion and agitation for 2 days
HPI: patient has been complaining of intermittent headaches, palpitations with feelings of
lightheadedness and flushed skin for the past several months. Reported by the wife.
Medications: metoprolol 25 mg BID
omeprazole 20 mg QD
Allergies: Penicillin
Past Medical Hx: HTN, GERD
Patient was hospitalized for left inguinal repair - 2013,
nissen fundoplication - 2009
Family Hx: Mother - HTN, alive
Father - COPD, deceased
Social Hx: married, 2 daughters. Does not use illicit drugs, tobacco products and drinks 2 beers
on the weekends. COnsumes a normal diet consisting of vegetables and fruits. Does not
exercise regularly.
Occupations Hx: sales representative for pharmaceutical company
Vital Signs: HR 110 bpm, RR 26 bpm, BP 215/132
Review Of Systems:
General: agitated and diaphoretic
CVS: no murmurs, heaves or thrills present. s1 and s2 are normal. s3 and s4 are not present
Respi: no crackles, rales or wheezes heard, clear sounds heard bilaterally
GI: no tenderness elicited during palpation, no hepatomegaly, no splenomegaly
Neuro: disorientated, 0X1, DTR are brisk and symmetric
Psych: agitated, confused
Physical Examination: fundscopic exam papilledema
Urinalysis is normal and drug screen is negative.
Lumbar puncture reveals no red or white blood cells, no xanthochromia, and normal content of
protein and glucose.
Labs: Hb - 16.5 g/dl, Na - 139mEq/L, K - 4.7mEq/L, Cl - 105 mEq/L, HCO3 - 29 mEq/L, BUN 32 mg/dL, creatinine - 1.3 mg/dL
Assessment: Aortic regurgitation

Medication Non-adherence

Plan: Reevaluate Medications

Patient Education