Dec 14, 2001 Dr. EE Internest Office Visit
Patient presents for follow-up of his chronic fatigue syndrome with unusual motor sensations, probable depression, and hyperlipidemia.
Medications: 1) Aspirin 81 mg/day, 2) Lipitor 20 mg/day, 3) Provigil 200 mg/day, 4) Remeron 45mg/day, 5) Wellbutrin SR 450 mg/day, 6) magnesium supplementation.
Patient otherwise is doing well. He has no acute complaints. Recent blood tests show a cholesterol of 192 which is improved with an LDL of 104, glucose of 111 and normal electrolytes, LFT's
On examination he appears well, BP is stable at 132/70. Chest is clear. CV exam is unremarkable. Abdomen is non tender.
Impression:
1) Fatigue syndrome - recent intracellular magnesium stable.
2) Depression - patient is now on slightly lower doses of Provigil and Remeron and will monitor.
3) Hyperlipidemia - doing well on higher dose of Lipitor 20 mg/day.
Plan follow-up in 4 months.
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