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)".

---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.

---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.


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.

---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.

---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.


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.

---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 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.

---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.

The patient sleeps 5 out of every 24 hours, on the average. The patient has trouble sleeping and complains of fatigue/sleepiness.


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)

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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