Reference no: EM131665331
SUBJECTIVE
Fred, a 62-year-old male, presents to the primary care clinic with the chief complaint of fatigue. Upon further questioning, he also reports some difficulty concentrating and a decreased sex drive. Further review of symptoms reveals dry skin, left knee weakness, occasional heartburn, and polyuria and wheezing on exertion. He denies any chest pain or palpitations. He reports being on antidepressants in the past but did not take them as directed. He is easy to get along with, forthcoming in his complaints, and describes his fatigue as a little bit more pronounces in the last couple of months. He also complains of erectile dysfunction, which he has noticed is worse in the last few years, especially since his diabetes is out of control.
Past Medical and Surgical History: Significant for uncontrolled type 2 diabetes, insulin dependent. The patient reports the last hemoglobin A1c of 10.2. He also has hypertension, gout, obstructive sleep apnea (with refusal to wear CPAP), and dyslipidemia. His past surgical history includes a deviated septum repair 20 years ago.
Family History: His mother died at the age of 81 of Parkinson's disease; his father died at the age of 57 of Hodgkin's disease; and he has one sister who is alive and well at the age of 58.
Screening: He had a negative colonoscopy in 2008. His most recent PSA value was 3.1 in 2007.
Social History: He reports drinking 2 drinks of hard liquor daily. He quit smoking 20 years ago and drinks 4 cups of coffee every day. He reports not adhering to his prescribed diabetic diet and has many financial and marital stressors at home. He is self-employed with some college education.
Medications:
Humalog, 75/25, 20 units in the morning and 20 units at night
Nexium, 40 mg daily
Crestor 10 mg daily
Allopurinol, 300 mg daily
Trazodone, 150 mg at night
Lopid, 600 mg twice daily
Baby aspirin, 81 mg daily
Micardis 40/12.5 daily
Actos, 30 mg daily
Allergies: NKDA, NKFA, or environmental allergies. All immunizations are up to date.
OBJECTIVE
Vital signs: Temp 98, Pulse 72, RR 20, B/P 138/90. His weight is 312 lbs. and his height is 58 inches.
General: He has a very pleasant attitude. His is a morbidly obese male, calm, pleasant and in no acute distress.
Skin: His color is pale. His skin is clear. Small senile keratosis is noted on his left arm.
HEENT: Negative
Neck: He appears to have short neck syndrome. He has not palpable nodes, no JVD.
Cardiovascular: Regular rate and rhythm. S1 and S2 are present without any murmurs, rubs, or gallops.
Respiratory: Breath sounds CTA with equal rise and fall of chest.
Abdomen: Obese, nontender, bowel sounds present in all four quadrants.
Musculoskeletal: Full range of motion to all four extreme.
Genital: He has normal genitalia. There is no evidence of swelling. His testicular exam is normal and there is appropriate hair growth:
List at least 3 differential diagnoses (rule in or out by history, exam, or lab work).
Create a plan of care for this patient.