Chief Complaint: Fatigue and decreased libido.
Chief Complaint: “Fatigue and decreased libido.”
History of Present Illness
A 37-year-old man with a history of HTN and obesity visits his primary care physician complaining of weariness. He is a married man with three children who works as an accountant. The patient indicates that he has gained weight, become weary, and is less inclined to work in the last year. He has also seen a drop in libido, which is causing marital stress. He recalls being much more active 5 years ago, going to the gym and running daily, but today he lacks the energy and motivation to exercise. He’s gained weight steadily over the years. Over the last six years, he has gained approximately 75 pounds.. When asked about his mood, he describes being depressed and he has not been going out with his friends or his family. He says he sometimes sleeps until someone wakes him up or he is “forced” to get up.
Review of Systems
The patient’s ROS is positive for fatigue, weight gain, decreased libido, lack of motivation, and distraction at work with difficulty concentrating. His ROS is negative for dry hair or nails, constipation, palpitations, SOB, or chills.
The patient has a history is significant for HTN and obesity that developed over the last 3 years. Patient denies any surgeries and denies any family history of cancer or thyroid disease. He does report his mother has HTN. He denies drugs and tobacco. He drinks 2 to 3 beers once or twice a month.
Allergies: No known drug allergies; no known food allergies.
Medications: Lisinopril 5 mg daily.
Vitals: T 36.5°C (97.8°F), R 20, P 72, BP 134/79, HT 177.8 cm (70 in.), WT 110.7 kg (244 lbs), BMI 35.
General: No acute distress, obese.
Psychiatric: Low affect.
Skin, Hair, and Nails: Normal turgor, no rash or dryness noted, no sign of hair loss.
ENT/Mouth: Moist mucosa.
Lungs: Clear to auscultation bilaterally.
Breasts: Gynecomastia bilateral, no masses.
Heart: RRR, no murmur.
Abdomen: Non-distended, non-tender, bowel sounds present.
Genital/Rectal: Testicles small bilaterally, length of testes measures approximately 3 cm bilaterally. No masses, no tenderness. No hernias. Rectal exam deferred.
Neurologic: No focal deficits.
Paper Format: Others
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