HPI: KF, a 56-year-old Caucasian female presents the to office with complaints of “no energy and not wanting to go out

HPI: KF, a 56-year-old Caucasian female presents the to office with complaints of “no energy and not wanting to go out
INSTRUCTIONS:
HPI: KF, a 56-year-old Caucasian female presents the to office with complaints of “no energy and not wanting to go out.” These symptoms have been present for about 3 months and seem worse in the morning and improve slightly through the day. It is hard to get out of bed and get the day started because does not feel rested when she wakes up in the morning.  KF reports a “loss of joy”. States” I really don’t feel like going anywhere or doing anything”.  She tries to do at least one social activity a week, but it can be really exhausting. Reports she also has difficulty completing projects for work, she cannot stay focused anymore. She reports not feeling hungry, so she is not eating regularly and has lost some weight.  KF has been a widow for 2 years. Her husband died unexpectedly, he had a MI. She recently got a puppy, which she thought would help with the loneliness, but the care of the puppy seems overwhelming at times. Rest and exercise, specifically yoga and meditation seem to help her feel better. At this time, she does not want to do either, it seems like too much effort to get up and go. She has not tried any medications, prescribed or otherwise. She reports drinking a lot of coffee, but that does not seem to help with her energy levels.
Current medications: Excedrin PM about once a week when she can’t sleep, seems to help a bit. NKDA.
PMH: no major illnesses. Immunizations up to date.
SH: widowed, employed full time as a consultant. Drinks 1 glass of wine almost every night. No tobacco use, no illicit drug use. Previously married 20 years ago while living in France, reports an abusive relationship. The French government gave custody of her son to the ex-husband. She returned to US without her son 10 years ago. She sees her son two times a year, they skype and text “all the time” but she misses him. Her son is now an adult and is considering moving to the US.
FH: Parents are alive and well. Has one son, age 21, he is healthy but lives in France with his father.
ROS
CONSTITUTIONAL: reports weight loss of 4-5 pounds, no fever, chills, or weakness reported. Daily fatigue.
HEENT: Eyes: No visual loss, blurred vision, double vision or yellow sclera. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose or sore throat.
CARDIOVASCULAR: No chest pain, chest pressure or chest discomfort. No palpitations or edema.
RESPIRATORY: No shortness of breath, cough or sputum

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