Chronic fatigue syndrome
Patient currently taking several medications that may be contributing to fatigue including gabapentin and ziprasidone. He is open to tapering gabapentin. He is also taking armodafinil (patient does not have narcolepsy or sleep apnea) and methylphenidate (there was a thought that patient may have a history of ADHD). Of note, patient was advised to increase his dose of methylene blue, which can increase risk of serotonin syndrome while patient is on methylphenidate.
Patient's strongly believes that the supplements and medications provided by Dr. MC are helping with his strength and energy. He states he is not open to discontinuing most of these despite my expressed concern that they may be causing harm at worst or at best are not providing benefit and are costing him thousands of dollars. I attempted to reach Dr. MC and request a medication list and past progress notes, but we did not receive anything back from his office. Patient would like me to speak with Dr. MC and reports that he will provide Dr. MC with our office phone number to reach me. Given patient is on ziprasidone, obtained an EKG today to get baseline, qtc is not prolonged.
Plan:Review of CBC and iron studies show that patient is not iron deficient and does not have Vitamin B12 deficiency. Can consider methylene blue causing hemolysis. Decided to defer labs today given patient's medications and supplements could be contributing to anemia and patient would like to discuss with Dr. MC about making medication changes before pursuing further work up of anemia.
Plan:Long term systemic steroid user
Patient taking hydrocortisone 10 mg daily (5 mg in the morning, 5 mg in the evening). Reason for long term steroid use is not clear. Patient does not have autoimmune disease, does not have indication for immune suppression, does not have history of adrenal insufficiency. Will attempt to reach Dr. MC, but in the mean time will place econsult to endocrinology regarding a recommended taper plan.
Summary from our visit today:
1. We are going to decrease the dose of gabapentin you are taking:2. I am going to ask the endocrinologists for recommendations on decreasing the hydrocortisone you are taking because I am worried about the long term effects of taking steroids.
3. When you speak with Dr. MC, you can give him our clinic's phone number: 415-353-4900. I will also try to get in touch with him again.
If you have questions for me, send a MyChart message or call our clinic at 415-353-4900. MyChart messages can be accessed by several of our staff members. We do our best to respond to messages within three (3) business days. If your medical need is urgent, please CALL our office at 415-353-4900. If your concern is not urgent, we may schedule a phone or telephone visit so that I can discuss with you in more detail. Otherwise our nursing staff will work to give you advice and will consult with me. If you need urgent advice after hours, call our main number 415-353-4900 to reach the operator and page the doctor on call. A doctor is available after hours 7 days a week for urgent advice.
Our clinic notes are available for you to review on MyChart. I hope this helps you better understand your health-- if you have questions about your notes please let me know so we can discuss.
CHRONIC FATIGUE -- Etiology of chronic fatigue not clear. Patient is taking multiple medications for wakefulness, including Armodafinil 218.75 mg daily and methylphenidate 55 mg daily, prescribed by outside psychiatrist. However he is also taking medications that may be contributing to fatigue, including gabapentin 1400 mg/day and ziprasidone 120 mg daily. He is also taking hydrocortisone 10 mg BID, unclear reason. I sent record requests to Dr. MC and Dr. AK; I received records from Dr. AK that were handwritten. 04/16/25 Patient reports psychiatrist reocmmended he decrease dose of methylphenidate from 55 mg daily to 50 mg daily to reduce the risk of serotonin syndrome. He is open to tapering gabapentin./p>
POLYPHARMACY -- I am most concerned about polypharmacy in this patient who is taking 36 medications and supplements. He is taking multiple controlled substances (armodafinil, methylphenidate), for which the diagnosis is not clear to me. He is also taking sedating medications, which can certainly be contributing to his fatigue as well as put him at increased risk of cognitive impairment and fall. He is taking gabapentin and ziprasidone, for which the diagnosis is not clear to me. He is taking long term steroids, hydrocortisone, for which the diagnosis is not clear to me. I also worry that he is taking supplements that have no data to support their benefit, and there may be risks. I am also worried about possible interactions of these supplements with each other. 04/16/25 Today he reports that Dr. MC has recommended he increase the dose of molecular hydrogen and purchase a device from Amazon that increases the amount of hydrogen in his water. He states he was told that this will help his mitochondria to give him more energy. He states that the genetic test he underwent was done by Varienteyx labs and interpreted by Dr. RB. He also reports that Dr. AK has recommended he start taking Vitamin B12 and Dr. MC recommends that he take methyB12 drops. He also asks whether he should be taking aspirin, probiotic, and multivitamin. He reports Dr. AK recommended he decrease dose of vitamin D 5000 international units. patient feels strongly that the medications and supplements he is taking have helped him feel stronger. Reports that last year he spent $24,000 out of pocket on supplements. He is willing to reduce gabapentin and consider stopping hydrocortisone. The other supplements he does not want to stop.
OSTEOPENIA -- Patient is osteopenic by 2007 DEXA proximal femoral neck t-score -2.0. Will order repeat DEXA. Advise patient start taking Vitamin D 1000 international units daily and calcium 800-1200 mg daily. 04/16/25 He has DEXA scheduled for 5/16/25.
ANEMIA -- Etiology of anemia not clear. Patient is not iron deficient or B12 deficient. No apparent source of bleeding. 04/16/25 Discussed that he is not iron deficient or vitamin B12 deficient.
BALANITIS -- Start clotrimazole 1% cream, apply to penis twice daily for 14 days.
BPH -- Currently taking terazosin 4 mg daily
Was living in New York in the 60s, moved to San Francisco in the 70s. Worked as a computer consultant. Retired about 8-9 years ago. To fill the time he reads the paper, visits with friends, watch TV, rest, managing money. Enjoys working on computers reading articles, going on Second Life (social environment). Lives alone with no pets. Friends live nearby. Brother lives in suburban Chicago, "sort of close", talks to him once a week. Describes the relationship as "friends". Never married. He feels he would turn to his friend Russ. Friendship with Russ and other friends and friends on Second Life bring him joy, reading brings joy. Feels like he is leading a content life.
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Diagnosis
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