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National Colony, Aurangabad, 431001 · Mon - Fri: 9am - 5pm

Report #21 · Office & outpatient

Fatigue and Weakness

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Clinical note · #21

Office & outpatient

Patient Name: John Doe

Date of Birth: 05/20/1975

Gender: Male

MRN #: 123456789

Date of Service: 04/08/2024

Chief Complaint

Fatigue and weakness

History of Present Illness

Mr. Doe is a 49yearold male presenting with complaints of increasing fatigue and weakness over the past two weeks. He reports feeling tired even after a full night's sleep and has noticed a decrease in his exercise tolerance. He denies any chest pain, shortness of breath, palpitations, or dizziness.

Past Medical History

Hypertension

Hyperlipidemia

Type 2 diabetes mellitus

Medications

Lisinopril 10 mg daily for hypertension

Atorvastatin 20 mg daily for hyperlipidemia

Metformin 1000 mg twice daily for diabetes

Allergies

None known

Social History

Nonsmoker

Occasional alcohol use

Family History

Father had a history of heart disease

Review of Systems

Negative for fever or chills

Negative for recent infections or illnesses

Positive for increased fatigue and weakness

Negative for unintentional weight loss

Physical Examination

General: Appears wellnourished, no acute distress

Vital Signs: Blood pressure 130/80 mmHg, heart rate 78 bpm, respiratory rate 16 breaths/min, temperature 98.6°F

Cardiovascular: Regular rate and rhythm, no murmurs or gallops

Respiratory: Clear to auscultation bilaterally

Abdomen: Soft and nontender, no organomegaly

Extremities: No edema

Assessment and Plan

  1. Rule out anemia: Order a complete blood count (CBC) to evaluate for anemia as a possible cause of fatigue and weakness.
  2. Monitor blood pressure: Continue current antihypertensive medication, Atorvastatin 20 mg OD and monitor blood pressure regularly.
  3. Diabetes management: Continue current diabetes medication, Metformin 1000mg BID and monitor blood glucose levels.
  4. Lifestyle modifications: Discuss the importance of regular exercise and a healthy diet in managing his conditions.
  5. Followup: Schedule a followup appointment in two weeks to review lab results and assess response to treatment.

NP Note

Today, I assessed Mr. Doe's chief complaint of fatigue and weakness. Given his history of hypertension, hyperlipidemia, and diabetes, I recommended further evaluation with a complete blood count (CBC) to rule out anemia. I also discussed the importance of lifestyle modifications in managing his conditions.

MD Note

I reviewed the assessment and plan outlined by the NP. I agree with the proposed course of action and will review the CBC results at the followup appointment in two weeks.

Electronically signed by Sarah Brown, NP. Date: 04/08/2024. Time: 10:00.

Electronically signed by Mark Johnson, MD. Date: 04/08/2024. Time: 11:00.