CHIEF COMPLAINT: Elevated liver function tests.
SUBJECTIVE: The patient reports he had gallbladder out end of May, back to work the next day. He is still having some pain under the ribcage. He was supposed to go back to the surgeon but did not. He is having the same type of pain he was having before, but it is not as bad.
Regarding elevated liver function tests, little bit of fatty liver. He knows that he needs to exercise more, get eating habits under control. He is only allowed 174 pounds by military regulations, and he is at 206, but the second line of testing is body fat percent. He is authorized to be 24% and he is only 20%, which means the extra weight is in muscles apparently and it is acceptable.
The patient does mention medical history includes extensive back surgery; he has 2 titanic cages, and he also has had several lipomas removed just because they bother him.
The patient mentions that his mother was paralyzed from the waist down during surgery for an abdominal aortic aneurysm. He had 2 aneurysms apparently in the abdominal aorta and 1 in the ascending aorta, also had a pacer, and was a heavy smoker. The patient himself does not smoke but does chew tobacco, which I strongly advised against.
The patient quit tobacco totally 6 months ago.
Father died of Alzheimer’s disease at 66. His 4 kids are healthy, athletic. They live with their mother.
OBJECTIVE:
GENERAL: Muscular, young-looking male.
VITAL SIGNS: Weight 206 pounds. Height 70 inches. Blood pressure 132/92, repeat 130/98.
HEENT: Head is normocephalic and atraumatic. Pupils are reactive. Conjunctivae clear. TMs and canals normal. Pharynx without erythema. Dentition natural, good repair.
NECK: Supple. No JVD, mass, bruit, thyromegaly or nodule.
HEART: Regular rate and rhythm.
LUNGS: Clear to auscultation.
ABDOMEN: Soft and nontender. Normal bowel sounds.
EXTREMITIES: Without edema.
NEUROLOGIC: Reveals cranial nerves, motor strength, gait and mentation grossly normal.
ASSESSMENT AND PLAN:
1. The patient’s elevated liver function tests may have normalized since his gallbladder was out. They may persist, however, due to fatty liver. In any event, first step is probably to recheck them, so I have ordered a CMP and lipid panel.
2. Regarding elevated blood pressure, we would ask the patient to collect readings outside of this office and return in couple of months to go over them.
3. Regarding attempt to lose weight and lower cholesterol, offered nutritional counseling. The patient declines. He says he knows what he is supposed to do.
