Aug 16, 2002 Dr. EE Interests Annual Exam
Medications 1) Remeron 60 mg/day 2) Celexa 20 mg/day 3) Wellbutrin SR 450 mg/day 4) Provigil 200 mg/day 5) Lipitor 20 mg/day 6) aspirin 81 mg/day 7) Remeron didn't work.
Patient presents for his annual exam and overall is doing dramatically better. He is seeing a new psychiatrist and has had his Remeron discontinued as well as Provigil. He is now back on Celexa 20 mg/day and a trial of Zyprexa was unsuccessful because of sedation. His other medications are as noted above.
He denies fever, chills, chest pain, or shortness of breath and has a new job working as a computer consultant. He has no other actual complaints other than his unusual fatigue and motor sensations. He only reports mild fatigue with exposure to water.
Medications as noted above. He has no new allergies. Review of systems is otherwise unremarkable. He does not smoke and drinks minimally.
Recent blood tests show a cholesterol of 203 with a normal LDL of 100, normal electrolytes, normal CBC, and normal PSA. He is due for a colonoscopy later this month as well as an eye exam.
On exam he is a remarkably well appearing male who has lost 9 pounds as a result of being off Remeron and his weight is now 172. BP 122/75, respiratory rate of 14. He is afebrile with a pulse of 68 and regular. SKIN - reveals few simple nevi and numerous lentigines. HEAD and NECK - unremarkable, oropharynx is clear. BACK - reveals no CVA tenderness. CHEST - clear to A and P. CV - notable for an S1, S2 without S3, S4, murmur or rub. ABDOMEN - soft, supple, non tender without hepatosplenomegaly. GU - unremarkable. RECTAL - deferred. EXTREMITIES - non focal. NEUROLOGIC - non focal.
Impressions: 1) Depression - doing markedly better with new psychotropic medications and will monitor. 2 Hyperlipidemia - stable on Lipitor. 3 Health care maintenance - remains on aspirin. Needs eye exam. Colonoscopy later this month.
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