Ihuman: Maria Ash
CC: weight gain and fatigue
HPI: Ms. Ash is a fatigued appearing 41 year old female presenting today with a new onset of
increased
... [Show More] fatigue x3 months. She reports that she feels slightly better if she doesn't have to
exert herself too much, or after a good night's rest, but she never feels "back to normal". The
fatigue is associated with a 15-18 pound weight gain despite the patient adhering to a high fiber,
vegetarian diet. She also admits to recent changes in her normally regular menstrual cycle,
currently experiencing heavier, longer cycles. She reports constipation, despite infrequent use of
over the counter fiber laxatives. She describes her facial skin as increasingly dry. Her fatigue
and "mental sluggishness" makes working as a fitness trainer very difficult. She denies chest
pain, palpitations, shortness of breath, nausea, vomiting, temperature intolerances, or
depression.
ROS
General: Weight gain of 15-18 lbs in the past 3-4 months. Patient has been feeling fatigue
Skin/breast: Skin on her face seems dryer than normal. Denies rashes, sores, or bruising. Denies changes
in the color of moles. Breast: Denies lumps, pain, or discomfort. Denies nipple discharge. Performs selfexaminations.
HEENT & Neck: Head- Denies headache, dizziness, lightheadedness, head injury, trauma, or seizures.
Eyes -denies pain, dryness, redness, eye pressure, glaucoma, cataracts, floaters, or specks. Denies trauma
or tears. Ears- denies changes in hearing, pain, discharge, or ear infections. Denies tinnitus, vertigo.
Nose and sinuses- denies congestion or discharge, no bleeding or pain: no sinus pressure or changes in
smell. Throat/mouth- denies cough. Denies pain or sore throat. Denies hoarseness. Denies dry mouth,
pain, mouth ulcers, sores, bleeding gums, or cavities. Neck: Denies swelling or stiffness, lumps, or pain.
Cardiovascular: Denies pain in the chest, discomfort, heart palpitations, dizziness, decreased exercise
intolerance, or blue/cold fingers and toes.
Respiratory: Denies any coughing and sputum. Denies wheezing, shortness of breath, or painful
breathing, chronic cough, or sputum production.
Abdomen/GI: Patient has been suffering from constipation for the last 4-6 weeks. Has BM 1-2 times a
week. Shape of her stools have changed, they're smaller and more compact. Weight gain of 15-18 lbs .
Denies abdominal pain bloating, cramping or discomfort. Denies problems with nausea, vomiting,
diarrhea, or hemorrhoids. Denies food intolerance.
Genitourinary:Denies blood in urine, foul scent urine, polyuria, urinary infections or kidney stones.
Denies abnormal coloring in urine or hematuria.
Muskuloskeletal: Denies lower back pain, joint pain, redness, joint swelling, joint stiffness, or weakness,
shoulder pain, or hip pain. Denies arthritis or gout.
Neurological: Denies mood swings, memory, attention or speech. Denies shocks or spontaneous
movements, seizures, weakness, paralysis, numbness or loss of sensation.
Allergic/Immunologic: Denies asthma, allergies to dust, cat, pollen
Lymphatic/Endocrine: Patient states appetite hasn't been very good, has weight gain of 15-18 lbs in the
last 3 or 4 months. Denies heat or cold intolerance, polyphagia, polydipsia, increased sweating.
Hematologic: Denies hx of anemia, past transfusions, easing bruising or bleeding.
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Psychological: Patient currently has empty nest syndrome since her daughter has left to college
but says she'll eventually adjust just fine. Denies depression, nervousness, sadness, memory loss,
insomnia, phobias, delusions or hallucinations
Physical Exam:
General: Appearance is normal for age. Patient cooperative with good affect congruent with
mood.
Skin/breast: Skin is warm and dry, No pallor, with normal turgor. No clubbing on nailbeds, with
normal capillary refill. Breast: symmetric, no masses or tenderness noted on palpation. Nipples
free from discharge
HEENT & Neck: Head: head normal cephalic, smooth with no lesions. Normal hair distribution.
Eyes: 20/20 visual acuity in each eye. Confrontation fills visual fields. Pink conjunctiva, white
sclera with no lesions. Equally sized pupils that are reactive to light. Ears: Bilateral and equally
sized ears. Insignificant elements of moist, and a yellow cerumen observable in ear canal. No
discharge, swelling or redness noted. Whisper test 3:3. Nose: Nares patent, septal deviancy and
perforation, no irregularity. No discharge noted in bilateral nares. No erythema or swelling of
turbinate. Neck: Trachea midline. No masses or tenderness. No JVD. Carotid pulse 2+. No bruits.
Throat/mouth: Uvula rises symmetrically. No nodules, ulcerations, erythema noted. Gag present.
Gums pink without redness or swelling. Tonsils pink and symmetric. Buccal mucosa, moist and
intact. Dentition intact.
Cardiovascular: HR Normal sinus rhythm, no murmurs, no gallops. No bruits. +pulses, cap refill
<2 sec in all four extremities.\
Respiratory: Thorax symmetric with good excursion. No cough noted. Normal breath sounds, no
use of accessory muscles. No crackles, wheezes, rhonchi, or rubs.
No tenderness, lumps or masses.
All superficial thoracic lymph nodes (axillary, infraclavicular, supraclavicular) are non-palpable
or of normal size and consistency .
The anterior lung fields are resonant
The left anterior chest (heart) and right lower chest (liver) are dull to percussion
The rest of the lung fields are resonant and are not hyper-resonant
Thorax atraumatic, w/o deformity.
Normal, symmetrical respiratory effort and excursion.
The lung fields are resonant
No evident rib fractures
Thorax symmetric with good excursion.
Abdomen/Gastro: No pain, tenderness, masses or pulsations
There is no guarding or rebound tenderness
No hepatosplenomegaly
Liver span normal
The spleen is not palpable
no hernia noted, tympany to percussion in all 4 quadrants, bowel sounds present.
Hypoactive bowel sounds
Genitourinary: No discharge noted. No redness or inflammation noted. No vaginal/cervical
lesions [Show Less]