DXR Harrelson Soap

Subjective:
HPI: Patient comes in today complaining of feeling fatigued for a long time. She is a poor historian
and is unable to give exact dates or details. Her mother is not in the office with her but she states that
her mother says her sleeping has been poor and that she snores a lot. She states that she has been
short of breath when she walks to work and that the fatigue is so severe she does not want to go to
work. She states that occasionally she wakes up with an inability to breath. She also complains of a rash
that has been going on for quite some time. She states that it is on her upper and lower extremities and
sometimes on her abdomen. She states that it worsens in the winter and sometimes the itching gets so
severe that she scratches herself until she bleeds. She has seen a physician for this previously and he
prescribed a cream that helped some.
Past Medical History: She denies any prior problems other than the rash. She states that her
immunizations are up to date. She denies any past surgeries.
Social History: Patient lives with her mother. Her sister did live with them until recently, when she
married and moved out. She denies any tobacco, alcohol, or illicit drug use. She works in a workshop
were she wraps silverware. Her mother is retired and lives on a fixed income. They are not financially
stable. She denies having a boyfriend. She states that she was molested as a child by her brother who
no longer lives with them. She states that she is handling this part of her past well mentally. She is a
high school drop out.
Allergies: No known drug allergies.
Family History: Father died of lung cancer and was a smoker. Her mother recently had a MI but
recovered well. Her mother also suffers from depression. Grandparents are deceased, reason
unknown.
Current Meds: Ginko Biloba to help her think.
ROS:
Constitutional: Denies fever, chills, unintentional weight loss/gain. Complains of fatigue that is
severe to the point that she does not want to go to work. Mother states that she sleeps poorly and
snores very loudly. She is unsure of how long the fatigue has been going on.
Eyes: Patient denies any visual changes, eye drainage, redness, or pain.
ENT: Denies any headaches, dizziness, ear pain/drainage. Denies any nose bleeds or other nasal
discharge. Denies sore throat, swelling/pain of the tongue, or bleeding of the gums.
Respiratory System: Denies any wheezing, cough, or mucous production. She complains of
shortness of breath when she walks to work. She also complains that sometimes she wakes up at
night with difficulty breathing.
Cardiovascular: Denies any palpitations, chest pain, swelling of extremities, coldness in

extremities, or exertional dyspnea.
Gastrointestinal system: Denies any pain of the abdomen, nausea, vomiting, change in appetite,
indigestions, constipation, or diarrhea. Denies any blood in his stools.
Genitourinary system: Denies nocturia, urinary frequency/urgency, incontinence, or urinary
retention.
Skin: Complains of red, scaly, pruritic rash on her upper and lower extremities. States that it has
been going on for a long time. She states that she scratches the rash so severely that it
occasionally bleeds. She also states that it is worse in the winter.
Endocrine: Denies any heat or cold intolerance. Denies any hair changes. Denies any dry skin
or excessive thrist.
Musculoskeletal System: Denies any joint pain, swelling, or stiffness. Denies any difficulty
walking, muscle pain, or cramps.
Neurologic System: Denies any change in mental status, increase forgetfulness, or nervousness.
She states that her face is asymmetrical because when she was born the forceps hurt her.
Pscyh: Denies anxiety or depression.
Hematologic/Lymphatic: She denies any bleeding or easy bruising. She denies any lymph node
swelling or pain.
Allergic/Immunologic: She denies taking allergy shots or cortisone shots. She denies HIV.
Objective:
Physical Exam:
BP: 120/80
P: 60
R: 16
Temp: 98.6
HT: 56 Wt: 350
Physical Examination.
General: Morbidly obese caucasian fe male who is well developed and well nourished in
appearance. No distress or anxiety noted.
Head: Normocephalic.. Negative TMJ. No lymphadenopathy or sinus tenderness noted.
Eyes: PERRLA.
Ears: Tympanic membranes intact and pearly gray in color. No fluid or irritation noted. No
masses or lesions.
Nose: Septum midline. Nasal turbinates not swollen and nasal passages are clear. Mucosa pink
and moist. No polyps noted
Mouth: Several missing teeth noted. Numerous fillings noted. Mucosa pink and moist. Tongue
midlines with no lesions or swelling noted. Gums pink with no disease or bleeding noted.
Neck: No lymphadenopathy noted. Thyroid reveals no enlargement or masses. Trachea midline.
Symmetrical and supple.
Skin: Fine, scaly, erythematous rash noted on bilateral upper extremities from the elbows down.
Obvious signs of scratching. Fine, scaly, erythematous rash noted on bilateral lower extremities
from about mid-calf down. There are signs of chronic scratching. Hyperpigmented skin noted
from chronic scratching.
Respiratory: Chest rise and fall is symmetrical. Respirations are unlabored. Breath sounds are
clear.
Cardiovascular: S1 and S2 heard. No murmurs, rubs, or gallops noted. Rhythm regular.
GI: Abdomen reveals no distention. Morbidly obese. No pulsations noted. Bowel sounds noted
in all 4 quadrants. No tenderness to palpation.
Lymphatic: No lymphadenopathy or tenderness noted.
Musculoskeletal: Normal gait. Full range of motion and denies pain with movement. No crepitus
noted.
Neuro: Right sided face asymmetry noted from trigeminal nerve damage during birth. Patient
alert and oriented. Full strength noted in upper and lower body.
Labs/studies: Sleep study revealed 3 major awakenings and snoring was rated at a 9/10.
Conclusion was severe obstructive sleep apnea. Normal CXR and CBC. TSH was slightly elevated.
Random blood glucose was 120. Visual acuity was 20/20.
Assessment:
Primary diagnosis:
Sleep apnea
Eczema
Differential Diagnosis:
Hypothyroidism
Diabetes.
Sleep apnea.
Eczema
Plan:
The patients primary diagnosis is sleep apnea which was verified by the sleep study. We will
order a CPAP which will be fitted through DME. We will send the patient for a referral to
pulmonology for her sleep apnea and dietician due to her severe obesity and her lack of
knowledge about her diet. We will also treat her eczema with betamethasone dipropionate
0.05% ointment to apply to affected areas twice a day for two weeks. This should calm the intial
inflammation from the eczema. The patient will then begin hydrocortisone 1% cream to apply
daily. The patient will take lukewarm bathes and apply moisturizer to affected areas throughout
the day. We will also begin the patient on Claritin 10 mg daily. We will send the patient to
counseling due to her past history of molestation. We will also contact social services to help the
patient with possibly meals on wheels and other monetary assistance. Educate the patient on a
low calorie diet and exercise to help with morbid obesity. Instruct the patient on risks of obesity.
Follow up one week status post CPAP installation to discuss sleep apnea and eczema.

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Subjective:

Cardiovascular: Denies any palpitations, chest pain, swelling of extremities, coldness in

HT: 56 Wt: 350

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