Brian Eberly: The Case, May 27th

HPI:

May 27^th:

Brian Eberly is a 53-year-old male patient who presents to his primary care physician concerned for gaining a lot of weight over the last six months. He also reports feeling “exhausted” even though he sleeps well at night. He can’t figure out anything that he is doing differently, other than being less active due to feeling “tired and weak all the time” and eating more than he used to because he “feels hungry all the time”. His sex drive is diminished, and he feels like he might be getting depressed because he just doesn’t enjoy going out to baseball games and taking road trips with his wife on the weekend like he used to.

Past medical history is significant for hypertension and hyperlipidemia. He has been treated for bronchitis five times in the last 3 years and was sent for pulmonary function tests last year, which showed an FEV1 of 70% predicted and an FEV1/FVC ratio of 0.65. He was told that he had COPD at that time.

Past surgical history: None

Medications:

Ipratropium inhaler

Amlodipine 10 mg daily

Lovastatin 20 mg daily

Social: He smokes 1 PPD.

ROS: He hasn’t had any changes in his vision, memory or ability to pay attention, hearing, swallowing or speech, no new neck or back pain, changes in bowel movements or dark bowel movements, urination patterns or amount, or new joint pain. He has some mild shortness of breath occasionally with doing chores or heavy work, “because I’m so out of shape” that hasn’t changed much in the last year. He has been using his ipratropium inhaler several times a day with some temporary improvement in his shortness of breath.

Physical Examination:

General: alert, talkative

HEENT: Pupils reactive and equal, eye movements are intact, visual fields are grossly normal, full neck range of motion without pain. No jugular venous distention, thyroid normal size without nodules. No lymphadenopathy is palpated.

Thorax: some mild wheezing bilaterally that is stronger with forced exhalation.

CV: regular rate and rhythm, pulses 2+ in all extremities, good perfusion and cap refill

Abdomen: obese, no hepatosplenomegaly, no bruits

Extremities: no edema, deep tendon reflexes are normal

Mr. Eberly’s physician discusses getting some tests today and seeing him the following week to explain the results and plan for more testing, if necessary. 

A CBC and CMP are ordered and show: 

Pulmonary function tests are also performed and are unchanged from the year prior.