REASON FOR VISIT: Annual physical examination.
IDENTIFICATION: The patient is a (XX)-year-old male who comes for annual physical examination. He denies any complaints.
PAST MEDICAL HISTORY: Hypertension, abnormal LFTs, workup negative, chronic calcific pancreatitis, history of lung nodules, unchanged benign prostatic hypertrophy, history of elevated PSA with negative biopsy, bilateral renal cyst, stable, vitamin D deficiency, retroperitoneal lymphadenopathy, unchanged, and history of polydipsia.
ALLERGIES: No known drug allergies.
MEDICATIONS: The patient takes nifedipine XL 90 mg, saw palmetto, multivitamin, baby aspirin and Viagra p.r.n.
SOCIAL HISTORY: Married. He smoked 1 pack per day for more than (XX) years. Drinks about (XX) beers per week. No formal exercise. He has 3 children.
FAMILY HISTORY: Both his parents are deceased. Father died at age 70 of myocardial infarction. Mother died at age 86 of unclear reasons. No family history of colon cancer, diabetes or prostate cancer.
HEALTH MAINTENANCE: He had a colonoscopy done in (XXXX), which was negative. To repeat in 8 to 10 years. He states that he had received flu vaccine. Today, he wishes to get both pneumonia as well as tetanus booster dose. In the past, he had refused. No formal exercise.
REVIEW OF SYSTEMS: He denies any changes in weight. No visual problems. Wears glasses. Denies any skin changes. No shortness of breath or chest pain. No dizziness or palpitations. No nausea or vomiting. No changes in bowel movements. No blood in the stools. Denies any urinary problems. No joint pains. He states that sexually he has been active but unable to maintain his erections. In the last 1 year, no hospital admissions.
PHYSICAL EXAMINATION: The patient is an elderly male who appears to be not in any distress. Blood pressure is 142/82, heart rate 94, height is 5 feet 6 inches, 182 pounds, temperature 98.2, and O2 saturation is 98% on room air. Head: Atraumatic, normocephalic. Eyes: Pupils are equal, reacting to light. No pallor or icterus. Extraocular movements are intact. Ears: Normal tympanic light reflex. Oropharynx: Clear. Neck: Supple. Lungs: Clear to auscultation. Heart: Regular rate and rhythm. No murmurs or rubs. Abdomen: Soft. Nontender. No hepatosplenomegaly. Back: No CVA tenderness. Genitalia: Notable for small inguinal hernia on the left side. No palpable masses. Rectal: Normal rectal sphincter tone. Enlarged prostate, smooth. No nodularity was noted. Extremities: No edema or cyanosis. Neurological examination is grossly intact.
ASSESSMENT AND PLAN: The patient is a (XX)-year-old male who comes for annual physical examination. We would get fasting labs.
1. Hypertension, still borderline. The patient was counseled to quit smoking, which he states he is planning to, and if he needs any help, the patient was advised to call back. We would continue to monitor his blood pressure.
2. Normal LFTs. Workup has been negative.
3. CAT scan shows cholelithiasis and hepatic granuloma. We would get GI consult.
4. Benign prostatic hypertrophy. Currently, the patient denies any complaints.
5. Health maintenance: We would administer pneumonia vaccine as well as tetanus booster dose today. In the past, he had refused.
6. Fasting glucose. We would get HbA1c.
7. Vitamin D deficiency. The patient states that he does take vitamin D over-the-counter, so we will check his vitamin D levels.
8. Smoking. The patient was counseled and urged him to quit smoking and also alcohol because of abnormal LFTs in the past, which he states he plans to do. The patient denies any alcohol-related problems. We would see him again in 1 year for routine physical.