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GENERAL
MEDICAL HISTORY:
The patient is a 52 year old, married, right handed male,
working full-time. Race was described as white.
Birthplace: Detroit.
Height 69 inches, weight 225 pounds, BMI= 33.2.
According to NHLBI (National Heart, Lung and Blood Institute) classification,
the patient's BMI suggests "obesity Class I (BMI 30 to 34.9)".
SOCIAL HISTORY:
---The patient works full time as plumber. Previous occupation(s): pipefitter
in the Navy, general contractor.
---Reports a decline in work performance in recent months.
---Reports traffic accident in the past 12 months.
---Education: completed high school.
---Caffeine use: 4-5 servings per day. The patient states they use the
caffeine because of need it to function due to fatigue.
---Tobacco: Reports previous use of cigarettes and cigars. Denies past
use of pipe or smokeless tobacco. 1988
---Ethanol use: Yes. The patient admits to 15 standard drinks per week.
Will drink as many as 0 standard drinks on a single occasion.
---When asked about street drug use, the patient denies ever using them.
---The patient denies recent problems with personal relationships.
---Over-the-counter medications include antacids and
acid reducers for heartburn/ G.I. distress, medicines to prevent hair
loss, vitamins, sleeping aids to treat insomnia and products to give energy/keep
awake/caffeine/supplements.
---Classes of prescription medications include erectile
dysfunction medications, prescriptions for GERD/ulcers, prescription sleeping
medicines and blood pressure medicine.
---The patient lists their prescription medications as "hydrochlorthiazide,
Cialis, Ambien".
---The patient uses medical devices including wrist support.
---The use of agents to keep awake: feeling fatigued or sleepy even when
using these products.
FAMILY HISTORY:
---Living family members include mother and father.
---Deceased: maternal grandmother, maternal grandfather, paternal grandmother
and paternal grandfather.
---There is a known family history of alcoholism/substance abuse, cerebral
aneurysm, coronary artery disease, high blood pressure and obstructive
sleep apnea.
---No known family history of blood clots, dementia/memory disorder, depression,
kidney stones, diabetes, muscle disease, multiple sclerosis, Parkinson's
disease, pregnancy losses, seizures/epilepsy, suicide, stroke, tremor,
headache problems, asthma or COPD.
PAST MEDICAL HISTORY:
Allergy PMH:
--- Patient denies problems with allergies to specific allergens or seasonal
allergies.
Cardiology PMH:
---Reports hypertension and high cholesterol/triglycerides.
---Denies history of congestive heart failure, coronary artery disease,
myocardial infarction, arrhythmia, atrial fibrillation, open heart surgery,
coronary artery bypass surgery, cardiac pacemaker, problems with veins
in legs, problems with arteries in legs, heart murmur, pericarditis, heart
valve problems, surgical bypass of arteries in the legs, blood clots in
legs or phlebitis in legs.
Dermatology PMH:
---Patient denies history of severe acne, skin cancer, psoriasis or any
type of skin disorder.
Endocrinology PMH:
---The patient denies history of problems with the thyroid, adrenal, pituitary,
or parathyroid or being diagnosed with diabetes or elevated blood sugar.
---Denies history of diabetes.
ENT PMH:
---There is a history of recurrent sore throat and tonsil/adenoid surgery.
---Denies frequent laryngitis, previous nose surgery, previous ear surgery,
previous throat surgery, chronic or recurrent sinus infections, impaired
hearing, deafness or frequent ear infections.
Ophthalmology PMH:
--- Denies problems with the eyes, other than needing glasses, that required
the help of an eye doctor, including eye surgery, LASIK and other corrective
procedures or the use of glasses/contact lenses.The patient wears glasses.
GI PMH:
---Reports history of problems with GERD.
---Denies history of problems with esophagus/stomach/bowels/rectum, liver,
gall bladder, pancreas, GI cancer not already mentioned, hemorrhoids,
liver disease, gall bladder disease, colitis, problems with pancreas or
other GI problems in areas not mentioned above.
Urology PMH:
---Denies history of any disorders of the bladder, kidneys or ureters.
Hematology PMH:
--- Hematology PMH: Denies history of anemia, a bleeding/clotting disorder
or exposure to blood transfusions.
Neurology PMH:
---Neurology PMH: Denies past or present problems with brain, spine or
nerves, epilepsy, seizures, multiple sclerosis, neuropathy, stroke, brain
tumor, severe headaches or other neurological problems.
---Denies history of neurosurgical procedure on brain or spine.
Ortho PMH:
--- The patient denies a past history of fractures.
Psychiatry PMH:
---Denies having been treated by a psychiatrist or others for depression,
anxiety, ADD, ADHD, panic disorder or any other behavioral problems.
Pulmonary PMH:
---Denies being diagnosed with breathing problems such as asthma, emphysema,
blood clots in the lung, chronic bronchitis, or any other respiratory
ailments.
Rheumatology PMH:
---Denies history of arthritis, gout, osteoporosis, osteopenia, lupus
or other rheumatologic illnesses.
REVIEW OF SYSTEMS:
Allergy ROS:
--- The patient denies symptoms related to allergies.
Cardio ROS:
---The patient reports difficulty breathing/shortness of breath, shortness
of breath with minimal exertion and fatigue.
---Denies swelling of the ankles or feet, chest pain/pressure/discomfort,
fast/slow/irregular/otherwise abnormal heartbeats, fainting, shortness
of breath when lying flat for a while, shortness of breath which awakens
patient from sleep, palpitations, rapid heartbeat, excessive sweating,
abdominal swelling, frequent urination or decreased muscle strength.
Dermatology ROS:
---Patient has dermatological symptoms, including hair loss.
---Denies suspicious moles, sores that bleed, sores that will not heal,
rashes, itching, nail changes, lumps on the skin or under the skin or
color change in the skin.
Endocrine ROS:
---Patient denies intolerance to heat or cold, diaphoresis, unusual hair
growth, excessive thirst, craving salt or noting enlarging hat or glove
size.
---Patient reports hair loss, fatigue and poor concentration.
---Denies cold intolerance, excessive sweating, frequent urination, pain
in the throat, lump in the neck or throat, swelling in the neck or throat,
frequent hoarseness, muscle pain or joint pain in general.
ENT ROS:
---Patient reports dry mouth.
---Denies sore tongue, ear pain, trouble with nose/sinuses, trouble with
throat/mouth/gums/teeth, hoarseness, throat pain, lump in the neck/throat,
swelling in the neck/throat or persistent cough.
Ophthalmology ROS:
--- Denies problems with eyes or vision, including eye pain and/or visual
problems of any kind, including double vision or blurry vision.
GI ROS:
---GI symptoms specifically include heartburn, burning feeling behind
the breastbone after eating and esophageal reflux.
---Denies loss of appetite, constipation, diarrhea, abdominal swelling,
abdominal pain, nausea or vomiting, change in bowel habits, bowel incontinence,
rectal pain/bleeding/itching, lump in groin, black or tarry stools, jaundice
or blood in stools.
GU ROS:
---Patient denies having problems with urination such as: pain, incontinence,
nighttime urination, burning urination, hesitancy, hematuria or any GU
problems.
---Patient reports problems with urination, including difficulty with
erections and lack of desire for sex.
---Denies frequent urination, difficulty with erections or lack of desire
for sex.
Hematology ROS:
--- Patient denies easy bruising, prolonged bleeding or enlarged lymph
nodes.
Neuro ROS:
---Denies neurological symptoms such as dizziness, lightheadedness, fainting,
seizures, weakness/paralysis, numbness, tingling, shaking, imbalance,
walking problems or speaking problems.
---Denies sudden losses of muscle tone, shaking or tremor, dizziness,
unexplained fainting, muscle pain, decreased muscle strength or shaking
or tremor.
Psych ROS:
---Denies symptoms of anxiety, depression, poor concentration, intrusive
or repetitive thoughts, memory loss, hallucinations, fears or leading
an excessively stressful life.
---The patient experiences poor concentration and fatigue.
---Denies irritability, anxiety, nervousness, fear, feeling flushed, lack
of interest/pleasure in doing things or a stressful life.
PHQ-9 depression screen:
--- The patient responded "not at all" for the following items
in the past 2 weeks:
a. Little interest or pleasure in doing things, b. Feeling down, depressed,
or hopeless, c. Trouble falling asleep, staying asleep, or sleeping too
much, e. Poor appetite or overeating, f. Feeling bad about self, like
a failure, let yourself or family down, h1 . Moving or speaking so slowly
that other people could have noticed, h2. being fidgety or restless, moving
around a lot more than usual, i1. Thinking that you would be better off
dead and i2. you want to hurt yourself in some way.
--- The patient experienced the following symptoms for "nearly every
day" in the past 2 weeks: d. Feeling tired or having little energy
and g. Trouble concentrating, like reading the newspaper or watching TV.The
depressive symptoms have caused some difficulty performing the patient's
daily tasks.
--- Anxiety symptoms include trouble sleeping. Denies
feelings of restlessness, feelings of muscle tension, feelings of anxiety
occurring more than half the time, difficulty controlling the worry or
anxiety which impairs daily function.
---The patient described symptoms which can occur during
panic attacks, including difficulty breathing/shortness of breath.
Respiratory ROS:
---Denies problems with coughing, wheezing, shortness of breath, painful
breathing or other respiratory symptoms.
---Reports respiratory symptoms, including shortness of breath with minimal
exertion and difficulty breathing/shortness of breath.
---Denies persistent cough, shortness of breath when lying supine, awakening
with dyspnea, fatigue after exercising or exercise induced wheezing.
Rheumatology ROS:
---Patient denies joint pain, back pain, neck pain, muscle pain or other
rheumatologic complaints.
---Denies joint pain or muscle pain.
Surgical hx: tonsil/adenoid surgery and appendectomy.
Denies history of gonorrhea, syphilis, genital herpes, HIV/AIDS, Chlamydia,
genital warts, Hepatitis B or Trichomoniasis.
Additional symptoms include no.
SLEEP HISTORY:
The patient sleeps 5 out of every 24 hours, on the average. The patient
has trouble sleeping and complains of fatigue/sleepiness.
DISCUSSION:
Discussion about insomnia: -The ISI score is consistent
with significant insomnia.
AASM Insomnia Criteria:
---A: MET: Reports trouble falling asleep, trouble staying asleep and
nonrestorative sleep. Denies early awakening
---B: MET: Reports despite adequate opportunity and circumstances for
sleep.
---C: MET: Reports sleepiness and concerns/worries about sleep.
Obstructive Sleep Apnea, Adult, is suspected on the basis
of:
--Ai: -- daytime sleepiness -- unintentional sleep episodes during wakefulness
-- unrefreshing sleep -- insomnia
--Aii: -- awaken with breath holding -- awaken gasping
--Aiii: -- bed partner reports loud snoring
Narcolepsy is at least suspicious on the basis of daily
or almost daily sleepiness for longer than three months.
The absence of cataplexy certainly does not rule out
narcolepsy. There were no symptoms of hypnagogic hallucinosis. There was
no history to suggest sleep paralysis.
Sleep Hygiene Discussion:
A. The patient's sx meet the criteria for insomnia: (YES)
C. Inadequate sleep hygiene practices are evident as indicated by the
presence of at least one of the following:
i. Improper sleep scheduling consisting of frequent daytime napping, selecting
highly variable bedtimes or rising times, or spending excessive amounts
of time in bed: NO
ii. Routine use of products containing alcohol (YES) especially in the
period preceding bedtime:
iii. Engagement in mentally stimulating, physically activating, or emotionally
upsetting activities too close to bedtime. (NO)
iv. Frequent use of the bed for activities other than sleep. NO
v. Failure to maintain a comfortable sleeping environment. (NO)
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Hypothyroidism is suspected on basis of fatigue-- weight gain -- cognitive
dysfunction --
Risk factors for coronary artery disease include hypertension, male gender,
Class I obesity, family history of coronary artery disease, sedentary
lifestyle, dyspnea with minimal exertion and hyperlipidemia.
PQRI Measure 173: Preventive Care and Screening for Unhealthy Alcohol
Use - Screening 2009 Criteria: As a male , under age 65, consuming 15
standard drink(s) per week, 5 drink(s) per occasion, the patient meets
the criteria for unhealthy alcohol use.
Risky behaviors include substance-abuse, traffic accidents, decline in
work performance and symptoms of unhealthy alcohol use.
The patient reports symptoms which are seen in asthma, including obesity,
dyspnea, dyspnea with minimal exertion, fatigue and insomnia.
Patient seeking help losing weight and to stop drinking.
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