42-year-old male complaining of Insomnia for years but has worse the past few years, the patient has not tried anything over the counter but drinks 3

Subjective

CC:

“I’m having trouble sleeping, I need something to help me sleep”.

HPI:

Onset– It has been going on for years but lately it’s getting worse

Duration– I can only sleep 2 to 3 hours a night and it’s affecting my work

Characteristics – My mind races, I can’t stop thinking and even when I fall asleep, I can’t stay asleep, I keep waking up every hour.

Associated/Aggravating– “I’m not sure”.

Relieving– “I drink beer to help me get tired and fall asleep. But I still wake up in the middle of the night”

Treatment- “I drink beer so that I can get tired”.

Summary– 42-year-old male complaining of Insomnia for years but has worse the past few years, the patient has not tried anything over the counter but drinks 3, “or more”, beers at night to fall asleep. However, patient reports waking up several times a night and waking up fatigued in the morning. The patient reports the lack of sleep is affecting his work and family life.

PMH:

Obesity-2000

Hypertension- 2011

Hyperlipidemia-2011

Allergies: NKDA

Medications:

Amlodipine 10mg daily

Atorvastatin 40mg daily

Social history:

Educational level/literacy- College degree in business management.

Smoking – Denies use of tobacco or cigarettes.

Alcohol- Drinks 3 or more, with a reported maximum of 6, beers a day.

Drugs- Denies illicit drug use

Sexual Health-Currently sexually active with female spouse.

Cultural and spiritual beliefs that impact health and illness- Patient denies. Financial resources – Patient is gainfully employed and denies financial need.

Family history:

Father: Deceased (2000)- Heart attack

Mother: Alive and Well-Hypertension, Diabetes, Depression. Maternal Grandmother: Deceased age 75-Cancer.

Maternal Grandfather: Deceased age 90- Natural causes.

Paternal Grandmother: Deceased age 80’s- Stroke.

Paternal Grandfather: Deceased Age 65- Heart attack.

Health Maintenance/Promotion:

Immunizations:

Up to date

Screening:

Nutritional counselling – Due

Review of Systems (ROS)

General: Reports fatigue, denies pain.

Skin: Denies itching or lesions.

HEENT: Reports ability to see well without glasses. Denies hearing difficulties. CV: Denies chest pain or discomfort.

Lungs: Denies cough or shortness of breath.

GI: Reports good appetite. Regular bowel movement, daily. Denies nausea or vomiting.

GU: Denies pain with urination, denies frequency or urgency.

PV: Denies calf pain or swelling.

MSK: Reports ability to walk with no assistive devices .

Neuro: Reports occasional headaches. Denies forgetfulness or dizziness.

Endocrine: Reports fatigue . Denies extreme thirst or hunger.

Psych: per Cc/HPI has insomnia, interests are being impeded by fatigue due to lack of sleep, denies feelings of guilt, reports focus and concentration suffering from lack of sleep, denies issues with eating or appetite, reports frequent feelings of anxiety, denies thoughts of suicide or self-harm.

Objective:

Physical Examination (PE):

Vital Signs: Blood Pressure 138/82, Pulse- 89, Respirations- 18, Temperature- 97.8(Oral), Oxygen Saturation-96% room air. Height 175.2cm, weight 280lbs, BMI- 41.34

General: Appears well groomed.

Skin: Warm, dry and intact.

HEENT: Eyelids in normal position. PERRLA. Extraocular movements smooth and symmetric. Ears equal in size bilaterally. No discharge. Lips pink and moist, no lesions.

Neck: Symmetric with no noted masses. Full range of motion. No jugular vein distention.

CV: Heartbeat regular, Apical rate is 84 beats per minute, S1and S2 sounds auscultated .

Lungs: Respirations even and unlabored. Lungs clear to auscultation

GI: Abdomen round and soft. No tenderness. Active bowel sounds x 4 quadrants. Umbilicus midline. Abdominal striae noted.

PV: No edema. No clubbing of fingertips. Bilateral extremities warm to touch. Strong pedal and popliteal pulses.

MSK: Normal flexion and extension. Able to overcome gravity. Normal spine curvature. Neuro: Alert and oriented. No tremors or unilateral weakness. Sensation intact bilaterally. No Babinski reflexes intact at 2+.

Diagnostic Tests: Lipid panel one month ago – Tot Chol 172, HDL 38, LDL 134,Trigs 156

Assessment:

Diagnosis/Diagnoses:

1. Insomnia

2. Alcohol use

3. Anxiety

4. Obesity

5. Hypertension – Stable with current medication.

6. Hyperlipidemia – Stable with current medication.

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