DOS: May 6, 2013
[Patient] was seen today in rheumatologic consultation on referral. This 71-year-old gentleman gave a chief complaint of longstanding fatigue and some muscle aches. He dated his symptoms to the 1960's, but has felt somewhat worse recently. He stated, "I live a 4 hour day." He has seen various physicians over the years, but was never found to have a serious organic condition.
The patient has a longstanding history of depression. He has had extensive psychotherapy and remains on several psychotropic agents. He feels that his mood currently is quite good. He generally sleeps satisfactorily and wakes up feeling fairly rested. However, he develops profound fatigue when sitting or standing more than 4 hours a day. He is able to watch movies on Netflix lying down without difficulty, but has fatigue if he tries to do so while sitting up. For many years, his symptoms have also been worsened by exposure to water.
His past medical history is generally quite unremarkable. Medications include atorvastatin, Cymbalta, gabapentin, Geodon, lamotrigine, methylphenidate, terazosin, and Wellbutrin. There are no known drug allergies.
Social history: The patient is a native of Chicago who fame to California more than 40 years ago. He is single. The patient is retired. He does not smoke or drink. He does stretching exercises 4 times a week.
Family history: The patient's father died at 73. His mother is living and in good health at age 92.
The patient's review of systems was largely as noted above.
On physical examination, the patient was a tall, slender, pleasant gentleman. Detailed musculoskeletal evaluation showed a full range of motion of all peripheral joints without evidence of synovitis. The patient's strength was normal on manual muscle testing. Deep tendon reflexes and peripheral pulses were intact.
I reviewed the extensive records provided by the patient. These included his own typed history, as well as a lengthy neuropsychologic evaluation by Dr. [...] from 3022. I also reviewed laboratory studies that he provided as well as those that were present in the electronic health record.
The patient has had extensive laboratory testing with minimal lab abnormalities. In late 2011, he had a negative ANA with an ESR of only 2 mm/hr.
This patient has very longstanding fatigue in association with a significant history of depression. There has never been any evidence of a serious inflammatory or autoimmune disorder. I reassured him that I found no evidence of a serious organic disease. I think his symptoms fall along the chronic fatigue syndrome spectrum in association, with longstanding depression. He is already on medications for this type of problem. I really do not have any additional therapeutic suggestions
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