Patient Information:
A.L., 38-year-old female, Caucasian, insurance unknown.
(S) Subjective:
CC: "tired all the time"
HPI: 38-year-old white woman
... [Show More] complaining of increasing fatigue over about 4 months. Feels tired all day, decreased interest in usual activities, less able to complete routine tasks, and generally slowed up.
Sleeping more than previously (now approximately 9 pm to 7:30 am) but does not feel rested. Does not wake during night or nap during day. No recent acute illnesses. No precipitating events for fatigue.
Family, friends and co-workers are criticizing her for low performance of usual activities and negative
attitude. Is not aware of other major symptoms. Is concerned "something is wrong" but can't specify a concern.
Current Medications:
Denies prescription medication. Takes daily multivitamin for last month. No regular use of OTC, herbal or other supplements. Tylenol @ 1-4 per month for shoulder/neck pains or headaches. Recently tried
Metamucil for constipation.
Allergies: NKDA.
PMHx: Denies past medical history.
PSHx: Denies past surgeries. Hospitalization for childbirth x3. G3P3 LC3.
Childhood Illnesses: None reported.
Immunization Hx: Unsure of immunization status. No recent influenza, tetanus.
Other Screenings: Last physical/pelvic/Pap about 3 years ago. No other screening. Does not do BSE.
Contraception by husband's vasectomy.
Soc Hx: Smoked ½ ppd from age 16-22. Drinks <2 glasses wine/month, no use of illicit substances Part-time teacher's aide in special education class (3 mornings per week). Currently not doing well at work, can't keep up with the stress.
Lives with husband and children. Family complaining about her lack of energy. Reduced housekeeping,
cooking, and family activities. No regular exercise. Stressed by family and work situation and ongoing financial concerns for family.
Fam Hx: Parents alive. Father 61-hypertension. Mother 59-type 2 diabetes, obesity. Sister 35-obesity, infertility. Brother 33-no health problems. Husband and children healthy.
Obesity, diabetes in several family members. No known cancer, strokes, heart disease.
ROS:
CONSTITUTIONAL: No reports of fever, chills. Reports increased fatigue starting 4 months ago. Appetite
reduced but eating more and gained about 10 lbs in 2-3 months.
HEENT: Reports mild headache, 1-2 per week. Vision may be less acute, hearing normal, no dizziness. SKIN: Reports skin and hair are drier than normal.
CARDIOVASCULAR: Denies chest pain, dyspnea on exercise/at night, swelling ankles. RESPIRATORY: Denies cough or wheezing.
GASTROINTESTINAL Appetite reduced but eating more and gained about 10 lbs in 2-3 months. Denies abdominal pain, nausea, vomiting and indigestion. Constipated recently with fair response to
Metamucil. No dark or bloody stools. GENITOURINARY: None reported.
NEUROLOGICAL: Reports feeling faint. Denies LOC, numbness and tingling. Reports hands and feet
cold.
MUSCULOSKELETAL: None reported. HEMATOLOGIC/LYMPHATICS: None reported. PSYCHIATRIC: Reports increased stress.
ENDOCRINOLOGIC: None reported. ALLERGIES: None reported.
O:
Vital signs: B/P 120/75, HR 60, T 98.0F, RR 12.
Height 5’4”, weight 158 pounds
BMI: 27.1
PHYSICAL EXAM
GENERAL: Looks older than age, overweight, well groomed, pale. Concerned but not in pain or distress. Intelligent and cooperative.
HEENT: atraumatic, normocephalic, EOMI, PERRLA. Mucosa moist. Neck: Supple with no masses/tenderness/lymph nodes. Normal thyroid. [Show Less]