SUBJECTIVE: The patient is a (XX)-year-old woman who is here for hospital dismissal visit. She was admitted on MM/DD/YYYY with confusion. Apparently, due to transient global amnesia, there were no worrisome findings on investigation for this.
There were no medicine changes. During the hospital stay, she says she felt like her thinking was not quite back to normal. She is still anxious about this.
She is asking about her B12 and other factors that might play a role. We reviewed her labs. Recent B12 level was very normal. The only thing of concern is that her creatinine recently went up from 0.67-0.96, which is higher than usual for her. She is on meloxicam through the pain clinic.
She is accompanied by her husband today, and we discussed her questions related to the confusion.
OBJECTIVE:
VITAL SIGNS: The patient’s weight is 224 pounds, which is 102 kg. BMI 36. Blood pressure is 138/80 with no drop on standing. The patient’s pulse rate is 64 and is regular. Temperature is 97.4.
She was able to get on and off the exam table without difficulty. She had no problems walking within the exam room, but when she went down the hall, she held on to her husband for support.
ASSESSMENT:
1. Transient global amnesia.
2. Slight rise in creatinine.
PLAN: The patient was counseled on her spell. We discussed stress management. We have suggested that the meloxicam might be stopped and nonsteroidals avoided if her pain allows with the rise in creatinine. The patient will follow up with her primary care physician as already scheduled.
