Comprehensive: fatigue, muscle aches, anger,
depression, anxiety, hot flashes
L.P. a 48-year-old female, married Caucasian presents for annual
exam in no apparent distress.
CC:
Generalized muscular aches, which she likens to flu symptoms, have
been ongoing for two years: fatigue, melancholy, feelings of anger,
impatience and internal lack of control. Symptoms intensify with lack
of sleep, and her needs are 8 to 9 hours minimum. Usually gets about
7 hours of sleep nightly. Unaware of any particular stressors, feels she
has a good life and was disturbed by her own thoughts and moodiness
during a vacation last winter. Is frustrated by her lack of
understanding the etiology of these negative, destructive feelings as
these are the antithesis to her behavior and feelings over her life.
Admits to feelings of anxiety, excessive warmth and need to leave
certain environments (as in a department store) over the last year on
several occasions. There have not been any periods of time in the last
two years in which she felt in control and happy. Related her
symptoms to her internist 2 years ago who initiated Amitriptyline 10
mg each HS for fibromyalgia with immediate relief of inability to sleep.
Two years ago she began to experience hot flashes, inability to sleep,
and increased melancholia following complete hyst for fibroids. She
was started on Premarin 1.25 mg with some relief of symptoms but
dose was increased to 2.50 mg for a period of time without significant
effects except that migraine headaches became a cyclical occurrence
every 28 days. Her headaches begin in the middle of the night and
intensify, lasting 24 hours. Movement, light, and noise cause
increased pain and nausea. Advil, three 200 mg tablets q 3 hours
takes the edge off and allows her to cope until her husband gets home
from work. Symptoms became more difficult to cope with, she had
memory loss on a daily basis and in August, the Amitriptyline dose was
increased to 25 mg each HS. Her memory improved with this dosage
change, but muscular achiness, fatigue and inability to cope continued,
so in October, her Amitriptyline dose was increased to 25 mg bid. She
senses a cycle each month wherein she feels life is tolerable for only
one week.
PMH:
Childhood illness: Nothing unusual.
Adult illness: Nothing unusual.
Surgery: Tubal ligation at age 26, tubal reconstruction at age 32.
Hysterectomy 6 months ago with cystocele and rectocele repair.
Opted to remove ovaries.
Hospitalizations: Six times - four for vaginal deliveries and three
during most recent pregnancies for hyperemesis and electrolyte
imbalance during first three months of pregnancies.
Accidents: One whiplash after car accident many years ago.
Psychiatric: Family involved in counseling over last 10 years to deal
with teenaged son’s addiction to drugs and to cope with marriage
demands, characterizes these sessions as helpful.
Current health status
Allergies: Skin reaction on exposure to penicillin.
Immunizations: Has received flu shots for last two years. Unable to
recollect last DT shot.
Diagnostic tests: Has had two mammograms in last 4 years, both
negative. Ophthalmologist last seen one year ago, presbyopic and
wears glasses for reading. DDS seen yearly.
Diet: Low-fat, balanced diet daily with adequate fiber and fruits and
vegetables. Adequate intake of fluids.
Exercise/Leisure: Rides stationary bike 3 to 4 times weekly for 20
minutes.
Environmental hazards: None. Wears seat belts and home equipped
with smoke alarms.
Medications: Currently on Premarin 1.25 mg daily, continuous.
Amitriptyline 25 mg bid and Advil 200 mg, tabs 3 to alleviate
headaches.
Caffeine: One cup of coffee and one cup of tea daily.
Nicotine: No history of smoking.
Illicit drugs: None.
Alcohol: 3 glasses of wine weekly.
Family history
Mother 70 years old and healthy. Father was alcohol dependent and
died of cerebral hemorrhage and CHF at 58. Her paternal grandfather
died at the same age as her father of cerebral hemorrhage, also
alcohol dependent. She is the oldest of 3 other siblings. Her sister is
schizophrenic, works one day a week and takes several medications.
Two brothers admit alcohol dependency, one is currently in control of
his drinking, the other is not. Eldest son is addicted to drugs, other
children healthy.
Psychosocial
Lives comfortably with second husband who works as a manager for a
department store and describes him as supportive. Two youngest
children also live at home. Eighteen year old son has had history over
past years of being a runaway, difficult to communicate with and is
currently as stable as he has been in 10 years living with her mother.
Her first husband was physically and verbally abusive (but not as
physically abusive as her father had been to her mother). He lives in
this area but has little communication with his children. Being the
oldest child, she frequently feels responsible for the well being of her
family including her sister, but does not spend much time with her due
to the demands of her young family. Active in her Baptist church and
has supportive friends.
ROS
Weight has remained stable. See CC.
HEENT: Migraines started on a regular basis last year, see CC. Had
one episode of severe headache that lasted 2 months during her first
marriage. She had a CT scan with dye contrast without significant
findings. Developed presbyopia last year and wears glasses. Now
notices some difficulty with distant vision and plans to see
ophthalmologist for this. Denies diplopia, blurred vision and
scotomata. No changes in hearing, earaches or dizziness. No postnasal drip or frequency of colds. No hoarseness or sore throats.
Skin: Notes formation of red mole-like formations on anterior trunk.
Neck: Denies swollen glands.
Respiratory: Denies cough, sputum production, SOB on exertion.
Breasts: Bilateral fibrocystic disease, more prominent on the right. No
nipple discharge or new lumps. Does monthly BSE.
Cardiac: Notes palpitations at times without specific pattern which she
does not find problematic, denies pre-cordial pain, ankle swelling,
PND, or SOB on exertion.
GI: No food intolerances. Was diagnosed with hiatal hernia during first
marriage but no ill effects or regurgitation for years. Stools are
regular without color or shape changes.
GU: Denies dysuria, polyuria, and hematuria. Denies stress
incontinence. Three vaginal deliveries with large babies. Two
miscarriages after tubal reconstruction, one of these progressed 3
months with severe nausea as did two subsequent pregnancies.
Hysterectomy with ovaries removed about 15 months ago. Pathology
report stated uterus was double the size and weight of normal.
Started on HRT. Mother was menopausal at age 46. Denies
dyspareunia, has frequent sexual relations with husband without
vaginal dryness.
MS: Generalized body aches all the time without alleviation with
NSAIDs, good ROM without warmth or swelling of joints.
Metabolic: Having frequent hot flashes or excessively warm spells that
may have been reduced somewhat with initiation of Premarin. Denies
polydipsia, polyphagia.
Psychiatric: Generalized fatigue, coupled with muscular aches,
impatience, anger and memory losses over a two year period of time
with brief alleviation when on Amitriptyline. Ongoing counseling for
family secondary to eldest son’s problems and combined family issues.
Has attended Alanon meetings as well as Adult Children of Alcoholics
and feels these have given her insights.
Physical exam
5’5 ½” tall, 136#.
BP 124/72.
Apical pulse 72 and regular.
Alert, oriented x 3, articulate and accurate historian who is well
groomed.
HEENT: Normocephalic, EOM intact, visual fields normal, PERRLA, red
reflex bilaterally, optic discs clearly defined. T.M.’s pearly gray
bilaterally without cerumen. Nasal septum intact, mucosa pink. Oral
mucosa pink, gums in close approximation to teeth, multiple fillings,
no caries or gingivitis.
Skin: No unusual growths. Numerous cherry angiomas anterior trunk.
Freckled skin on al exposed areas.
Neck: Trachea midline, no palpable masses on thyroid, no thrills,
negative lymphadenopathy.
Respiratory: Excursion equal bilaterally, vesicular sounds throughout,
no adventitious sounds.
Breasts: Bilaterally cystic without nipple discharge.
Cardiac: Normal sinus rhythm, 72, no murmurs, no carotid bruits, no
swelling.
Abdomen: Bowel sounds all quadrants. Liver and spleen non-palpable.
No tenderness or masses.
GU: Deferred, pap smear done this past summer.
MS: Good ROM throughout without joint swelling.
Neurological: Cranial nerves II-XII intact. DTRs equal bilaterally 2+.
Muscle strength equal bilaterally. Cerebellar function intact.