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Documenting the patient encounter (PLO 5)  HPI: Ezra Garcia…

Documenting the patient encounter (PLO 5)  HPI: Ezra Garcia is a 29 y/o male patient with a past medical history of mild intermittent asthma who presents with the complaint of “difficulty sleeping lately.” This started approximately 3 months ago. He describes the problem as difficulty falling and staying asleep, often reporting that he can’t turn his mind off when he puts himself to bed at night. He rates this as a “8/10” in severity overall. He notes that the symptoms have been worsening since onset. He notes that he has been sleeping more than usual on weekends when he is off of work, but still feels tired during the day.  Pt shyly admits that this is only part of the reason for his visit today, as he is also experiencing “many other symptoms” most days of the week for the last 3 months that have concerned him. When asked about this, he shares that this also includes increased generalized fatigue, decreased motivation to work or exercise, difficulty concentrating, and decreased productivity at work. Furthermore, pt reports he has been feeling “down and just sad most days of the week” and notes a loss of interest in activities he previously enjoyed such as photography and working out. He reports a decreased appetite and estimates he may have lost approximately 5-7 pounds over the last month without intentionally trying to lose weight. Pt also reports feelings of guilt about missing work after calling out a few times over the last month and worries he is “letting people down”. He notes that he just couldn’t get himself out of bed to go to work during those times that he called out of work.  Overall, pt reports that his symptoms have begun to affect his job and social interactions over the last month, worrying that he may lose his job if he misses any more work. He reports he has declined invitations from friends over the past several weeks because he “doesn’t have the energy” to get out and see them. Pt reports fleeting thoughts of “wanting to end it all” once or twice over the last 3 months, but denies active suicidal or homicidal thoughts or ideations. He denies having any plan of self harm or prior self harm attempt. He also denies any new or unusual difficulty controlling his asthma and denies any recent exacerbations or need for step-up therapy regarding his asthma.   Medications:  -Albuterol MDI inhaler (90mcg/actuation) – pt is instructed to take 2 puffs q4-6 hrs for asthma symptoms as needed.  -Cetirizine 10mg tablet – take 1 tablet PO daily during gross and pollen allergy season (March-June) -Clobetasol propionate 0.05% cream – apply to areas on hands/feet affected by atopic dermatitis BID PRN (limit 7 days consecutive use) Allergies: NKDA; pt admits to grass and pollen allergies otherwise.  Past Medical History: Chronic conditions:  Mild intermittent asthma; Atopic dermatitis (seasonally affects pt) Hospitalizations:  Once as a child for an asthma exacerbation (age 10), but none since Surgeries:  None Immunizations: Pt believes he is up to date on his required vaccines/immunizations. Family History: Father: alive, 60 years old. History of type 2 diabetes Mother: alive, 58 years old. History of depression treated with medication Sister: alive, age 27, hx of depression and opiate use/abuse and history of suicide attempt by intentional overdose with acetaminophen.  Brother: alive, age 21, hx of ADHD. Social History:  Tobacco/Vape: Daily use of electronic vape pen (4-5 times per day). No tobacco use. Caffeine Use: None Alcohol: Denies Illicit drugs: Occasional marijuana vape use (1-2 times per month for the last 3 years; unchanged recently) Marital/Sexual: Single Living situation: Lives in an apartment near El Cahon Job: Veterinarian assistant (works 8am-4:30pm Monday-Friday) Hobbies/Exercise: Walking his dog, photography, and working out. Previously worked out 2-3 times per week, but recently 0-1 times per week over the last 3 months.  Diet: Normal diet Religion: Atheist Sleep: Normally averages 6-7 hours of sleep per night normally, but significantly less recently. ROS Constitutional: See HPI. Positive for generalized fatigue, decreased appetite, and unexpected weight loss. Otherwise, pt denies fever/chills, night sweats, or confusion. Skin: Denies hair loss, nail pitting, rashes, lesions, or skin discoloration.  HEENT: Denies rhinorrhea, sore throat, congestion, ear pain or discharge, eye pain or change in vision, or headache. Denies hearing changes or tinnitus. No lymph node swelling reported. CV/PV: Denies chest pain or tightness, palpitations, or swelling or edema of lower extremities. No syncope or pre-syncope reported.  Pulmonary:  Denies SOB, coughing, wheezing, hemoptysis, stridor, dyspnea, orthopnea, or pain with inspiration.  GI:  Denies constipation, diarrhea, changes in stool, abdominal pain or distention, nausea or vomiting.  GU:  Denies dysuria, increased (or decreased) urinary frequency, urgency, or hematuria. Denies urinary incontinence.  MSK:  Denies muscle weakness, joint swelling or joint pain, or difficulty moving any joints. No changes in gait or myalgias. Neuro: Denies headaches, dizziness or lightheadedness, dysarthria, slurred speech, or focal weakness. Denies any known history of seizures or recent seizure-like activity. Psych: See HPI. Denies confusion, racing thoughts, suicidal ideation, homicidal ideation or hallucinations. Endocrine: Denies heat or cold intolerance, polyuria, polydipsia, or polyphagia.  Heme/Lymph: Denies any easy bruising or bleeding.   Question 3: Documenting the patient encounter: Based on the provided full patient history, respond to the following: Identify your suspected lead diagnosis. Then, identify and list ten (10) critical pieces of information to document in this patient’s chart for this case to support your lead diagnosis and/or decrease the probability of any other concerning diagnoses. [PLO 5] Provide a brief rationale for each critical documentation item provided as to why you feel it is important and relevant to document in this case.