Patient demographic info: Mr. NQ, 59y.

Date/Writer: 01/10/12, 2:30pm, ______, AMS 2 Source and Reliability of Information: patient, accurate historian CC: Today is my annual physical. HPI: Mr. NQ is a 59 year old man with a history significant for DM2, obstructive sleep apnea, restless leg syndrome, GERD, hypertension, hyperlipidemia, and depression presenting today for his annual physical exam. Regarding his DM2 maintenance, Mr. NQ notes that his blood sugars which he self-monitors by finger stick have been running high. He states that they are frequently in the 200's both in the morning as well as in the evening. He denies headaches, numbness, tingling, weakness, tremor, seizures, or dizziness. He also denies any difficulty with memory, blackouts, vertigo, balance or walking. He also denies changes in thirst or urination frequency or urgency. Mr. NQ admits to continued difficulty with sleep. He describes frequent thrashing and restless sleep with frequent starts from sleep. He continues to use his BiPAP machine to aid his apnea, but states that he needs to get a new mattress and box-spring, stating that his current bed has become misshapen over time. He feels generally fatigued for lack of sleep at all times. His energy level is accordingly stated to be quite low. Mr. NQ also admits that this effects his ability to concentrate on things such as reading the paper or watching TV. He denies fevers, night sweats, chills, changes in appetite, or changes in weight. Mr. NQ has been experiencing ongoing dental trouble, for which he is seeing a dentist. He has in recent years had a number of his upper teeth removed and states that he has an appointment soon for the removal of the remainder of his upper teeth. He will be fitted for a plate to replace them. Mr. NQ states that he has been feeling particularly down regarding this development. A PHQ-9 was performed and scored at 22. Mr. NQ also states that he has an appointment to see his psychiatrist in the immediate future. Mr. NQ's right 4th finger has been acting up lately, causing a dull pain in its metacarpophallangeal joint. He admits to decreased range of motion caused by it, but states that a previous consultation with a hand surgeon suggested nothing to be done for it. Of other note, Mr. NQ is schedule to see his GI specialist for a regular colonoscopy as well as a reevaluation of his esophagus. He denies heartburn, abdominal pain, nausea, or vomiting. He also denies changes in his bowel habits, although he admits to variability in his stool color, including occasional light colored stools. He denies bloody, black, or tarry stools. PMH: Type 2 Diabetes Mellitus Obstructive Sleep Apnea Restless Leg Syndrome Hypertension Hyperlipidemia GERD Iron Deficiency Anemia Depression Asthma Bruxism Trigger finger - right 4th finger

Childhood Illnesses: none Hospitalization: none Surgical: 1957 - Tonsillectomy 1991 - Ruptured Achilles Tendon 1998 - Uvulectomy 2000 - Orthognathic Surgery 2011 seasonal Flu 2010 Tdap 2002 Pneumococcal 1988 Hep B Amitryptaline 75mg tab Fenofibrate 134mg cap, 1x/daily Fluticasone 50mcg nasal spray Lisinopril 10mg tab, 1x/daily Omeprazole 20mg cap, 1x/daily Novolin 70/30 100unit/mL susp. SubQ injection, up to 50units 2x/daily Metformin 1000mg tab, 2x/daily Fexofenadine 180mg tab, 1x/day Clonazepam 0.5mg tab, 2x/day

Immunizations:

Medications:

Allergies: No known drug allergies Family History: Parents and siblings are stated to be living and healthy. No children. Uncle died at 62 of colon cancer, diagnosed at 55.

Social History: Mr. NQ is a licensed RN, but has been forced to retire due to disability in 1995. He lives alone in subsidized housing. He states that he is close to his family, but when asked if he can confide in them when feeling down, states that he generally [doesn't] want to bother them about his ongoing medical troubles. He states that his stress level is pretty high, and attributes that to his ongoing medical issues, particularly his teeth. He denies current or previous tobacco use. He also denies current alcohol or other drug use. He feels that his nutrition is adequate, but that he eats meals at odd times, due to his sleep difficulty. He would like to lose weight, and attempts to manage his diet accordingly, but is not currently exercising. He feels safe in his environs and denies any cultural, spiritual, or religious beliefs that might effect his health care. Review of Systems: General: See HPI (no constitutional symptoms) Skin: Denies changes to skin. Denies rashes, lumps, pruritis, dryness. Denies changes in hair or nails. Denies new moles or changes in size, shape, or color of existing moles.

HEENT: Denies trauma. Uses glasses. Denies changes in prescription. Admits to occasional burning of eyes with redness, itch, and dryness, but attributes that to lack of sleep. Denies changes in hearing or use of hearing aids. Admits to occasional, pulsatile tinnitus for several years. Denies discharge, or earaches. Admits to frequent congestion with occasional discharge. Mucus is stated to be yellow. Denies epistaxis. Changes in teeth noted in HPI. Denies changes in gums. Denies difficulty swallowing, sore throat, or hoarseness. Denies pain or stiffness, denies swollen glands, lumps, or goiter Pulmonary: Denies shortness of breath at rest or with exercise. Denies pain, wheezing, or cough. Mucus is stated to be yellow. Denies hemoptysis. Cardiovascular: Denies heart trouble, pain, pressure, or palpitations. Denies swelling of extremities. Generally uses 1 pillow for sleeping, sometimes none. Digestive: See HPI - (no abdominal symptoms) Genitourinary: Denies changes in frequency, force of stream, or urgency with urination. Denies hesitancy or dribbling. Denies blood in urine. Musculoskeletal: See HPI noted 4th MCP pain and diminished range of motion (can't close 4th finger tightly with making a fist). Denies other pain or stiffness in muscles or joints. Denies swelling, redness, or other changes in range of motion. Neurologic: See HPI - (no neurologic symptoms) Hematologic/Lymphatic: Denies easy bleeding or bruising. Denies recent travel. Psychiatric: Admits to feelings of depression, especially regarding teeth. Admits to changes in interest and pleasure. Denies feelings of nervousness and anxiousness. Denies thoughts of harming self or others. Physical Exam: General appearance: Well developed, well nourished. No acute distress. Demeanor is tired, but without flat affect. Vital Signs: BP: sitting, R arm, 140/80, reg cuff (initial) BP: sitting, L arm, 114/70, reg cuff (later in visit) BP: sitting, R arm, 118/74, reg cuff (later in visit) HR: sitting, 68 and regular Weight: 231 lbs Height: 68 BMI: 35 Skin: Supple and pale. No large, multicolored, or asymmetric moles noted. One achrocordon of approximated length 1mm noted in anterior left axillary region. HEENT: Normalocephalic, atraumatic. Conjunctiva are clear. Sclera are white and non-icteric. Field of vision is full to confrontation. EOM are coordinated and symmetric. PERRLA. Disc margins are

sharp bilaterally. No hemorrhages or exudates. Gross hearing is intact bilaterally. Auricle and tragus are non-tender. External canals are clear. TM's are translucent and show no errythema or bulging. Cone of light visualized bilaterally. Pink nasal mucosa. Septum midline. No sinus tenderness. Mouth MMM. Multiple teeth are noted to be discolored, chipped, and missing. Neck: No lymphadenopathy. No thyromegaly or mass. Heart: PMI well-localized at the left 5th intercostal space in the mid-clavicular line. No JVD. No lifts, thrills, or heaves. S1 and S2 are audible and distinct. No MRG. No carotid bruit. Pulses are 2+ bilaterally at carotid, brachial, radial, femoral, popliteal, posterior tibial, and dorsalis pedis. Chest/Lungs: Chest wall is symmetric and non-tender. Breathing appears unlabored with no evidence of accessory muscle usage. Expansion is symmetric. Tactile fremitus is symmetric bilaterally. Percussion is resonant throughout. Vesicular breath sounds. No rales, ronchi, wheezes, or rubs. Abdomen: Abdomen is round and symmetric without evidence of scars or lumps. Bowel sounds are active. No renal or aortic bruits. Abdomen is tympanic in 4 quadrants. No midline pulsatile mass. Abdomen is non-tender to light and deep palpation in 4 quadrants. No heptaosplenomegaly. GU: Uncircumsized, prepuce easily retractable. No penile lesions or discharge. Testes are descended bilaterally, non-tender, and without masses. No scrotal swelling or discoloration. No evidence of herniation bilaterally. Rectal: No perirectal lesions or fissures. External sphincter muscles 5/5. Prostate is smooth and nontender. Stool is brown. Stool guaiac is negative. Musculoskeletal: Joints are symmetric and without redness, swelling, or tenderness. Right hand does not form a full fist due to 4th finger not fully closing in fist. Full, active range of motion in all other extremities. Neurological: Cranial nerves: II-XII symmetric and intact Motor: 5/5 symmetric motor strength in all extremities. Sensory: Symmetric response bilaterally to light and sharp touch, proprioception, and vibration in all extremities. Cerebellar: Finger-to-nose and heel-to-shin tests coordinated, consistent, and symmetric in movement bilaterally Gait: Gait is symmetric and unlabored. Reflexes: 2+ and symmetric bilaterally at biceps, triceps, patella, and Achilles tendons. Plantar response is plantarflexion bilaterally. Formulation: In summary, Mr. NQ is an affable 59 year old male managing multiple chronic diseases. The high blood sugars are particularly worrisome as is his depression. The blood sugars suggest a need to reassess his medical management of his DM2. Appropriate scaled dosing up for the morning and otherwise an increase to 54 units twice daily was discussed and is believed to be reliable, as Mr. NQ was an RN. His HbA1c is due to be checked again in two months. Iron and CBC will be checked at the same time. If high blood sugars persist, Mr. NQ is encouraged to call and to not wait for his next appointment. Regarding his depression, Mr. NQ will see his psychiatrist within the month, as noted. It is believed that the completion of the noted dental procedure will help alleviate his

depression. Additionally, Mr. NQ will begin a trial of Gabapentin 400 mg cap 1x/daily at bedtime in an attempt to alleviate thrashing and restless symptoms. If effective, it is also believed that this will help to alleviate his depression. Reflection: While interviewing Mr. NQ it was clear that he keeps much of his feelings regarding his health to himself and was needing to talk about it. He brought up his feelings of depression multiple times during his appointment. Although he had some opportunity to discuss it with his doctor, he had considerable opportunity to do so with me. I think it helped him to speak more openly about his feelings of depression regarding the pending replacement of his upper teeth. It was concerning to me how depressed he was, and truthfully I felt uncomfortable with the decision to wait for his various appointments to pass, wanting for him a quicker passing of his depression. I imagine, however, that this will likely often be the case, as depression is not likely to be a quickly passing condition in anyone, let alone those with multiple debilitating chronic diseases. But the acute symptoms non-withstanding, it also seemed to me that he really ought to be seeing a therapist, as his general disability was clearly effecting his self-esteem and relationships with others. It is unfortunate to think that he would not have had the satisfaction of talking at length about his feelings during his visit were I not there.