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Old 05-23-2014
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Default Any feedback Plz.. PN.....

46 yo M, c/o fatigue x 3 months.
-constant throughout the day, fatigue began after unsuccessful attempt to save his friend after a car accident.
-Sleep disturbances, feelings depressed and helpless, suicidal ideation but not plans/attempts, good support (friends and family), decreased interest in his daily activities, feelings of guilty about accidents, low energy, decreased concentration, No psychomotor agitation.
- poor appetite but gained 6-lb of weight.
-No cold intolerance, hair loss, skin dry, constipation/diarrhea.
ROS: Negative except as above
Meds: none. ALL: NKDA. FH: Noncontributory.
PMH: Urethritis, treated 5 months ago. PSH: No trauma or hospitalization. SH: 1 PPD for 25 years, 2 beers/month. Multiple sexual partners; unprotected sex.

Patient is in no acute distress. Looks tired and flat affect, speaks and moves slowly.
VS: WNL.
HEENT: Sclerae white; conjuctiva pink. Mouth: Moist membranes; good dentition, no lesion. Pharynx without exudates or erythema.
Neck: No cervical or submandibular lymphadenopathy. Thyroid norma.
Heart: Normal S1/S2; RRR; no m,r,g
Lungs: CTA
Abdoment: Soft, nontender, nondistended. + BS. no hepatosplenomegaly.
Extremities: No edema, cyanosis.
Neuro: DTR: 2+ and symmetric brachioradial, knee and ankle jerks.

Major depressive disorder

fatigue x 3 months
Sleep disturbances, feelings depressed and helpless, suicidal ideation but not plans/attempts
decreased interest in his daily activities, feelings of guilty about accidents, low energy, decrease
SH: 1 PPD for 25 years, 2 beers/month. Multiple sexual partners; unprotected sex.

Sclerae white; conjuctiva pink
Mouth: Moist membranes; good dentition, no lesion. Pharynx without exudates or erythema
Neck: No cervical or submandibular lymphadenopathy. Thyroid norma.
DTR: 2+ and symmetric brachioradial, knee and ankle jerks.

Adjustment disorder
fatigue x 3 months
Sleep disturbances, feelings depressed and helpless, suicidal ideation but not plans/attempts
decreased interest in his daily activities, feelings of guilty about accidents, low energy, decrease
car accident

Sclerae white; conjuctiva pink
Mouth: Moist membranes; good dentition, no lesion. Pharynx without exudates or erythema
Neck: No cervical or submandibular lymphadenopathy. Thyroid norma.
DTR: 2+ and symmetric brachioradial, knee and ankle jerks.

Hypothyroidism

fatigue x 3 months
Sleep disturbances, feelings depressed and helpless, suicidal ideation but not plans/attempts
No cold intolerance, hair loss, skin dry, constipation/diarrhea.

Sclerae white; conjuctiva pink
Neck: No cervical or submandibular lymphadenopathy. Thyroid norma.
DTR: 2+ and symmetric brachioradial, knee and ankle jerks.
Extremities: No edema, cyanosis.

Mental status and neurologic exam
CBC, iron level, ferritin, TIBC, serum b12
Electrolytes.
TSH, FT3, FT4
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