SUBJECTIVE: The patient is a (XX)-year-old female who comes in to follow up on hyperlipidemia and for routine care. Last complete exam was in (XX) with Dr. (XX). She had a tetanus booster in (XX) as well. Last eye exam was in (XX), and she plans to schedule one in the near future.
She had a colonoscopy in (XX), which was normal. However, prep was not ideal, and 5-year repeat was recommended. She does have a secondary family history of colon cancer in a maternal uncle who apparently died quite young with this; however, her mother has not had any issues, and there are no other people with colon cancer in the family that she knows of.
She follows with an outside dermatologist due to history of squamous cell carcinoma and will be seeing him within the next couple of weeks. Bone density was updated in (XX). She does not have any particular acute complaints today. She does need a new prescription for her simvastatin.
Her past medical history includes borderline blood pressure, hyperlipidemia, history of carpal tunnel, depression, anxiety issues, squamous cell carcinoma of the nose, complete hysterectomy in (XXXX) for fibroids and bleeding, left knee pain, anxiety and stress issues, and neuroma of the foot.
Her current medications include simvastatin 20 mg daily. She takes multivitamin and calcium.
She has drug allergy to penicillin.
The patient is retired. She baby sits for three grandchildren usually about three half days a week. She has a long-term significant other of 15 years who is retiring shortly. She stopped smoking in (XXXX), previously smoked less than a pack a day for about (XX) years. She is not really doing a lot of exercise at the current time. She has 0 to 1 alcoholic beverage weekly.
Her family history includes cardiac disease in father who had myocardial infarction at age 80; hypertension in mother, father and sister; diabetes in sister; uterine cancer in mother. Mother with dementia. She has a sister with chronic obstructive pulmonary disease who was a heavy smoker. Maternal uncle with colon cancer who died young. No real changes.
Of note, when she saw Dr. (XX) for a physical last year, she was having significant family stressors due to conflicts regarding her mother, with her siblings. It was recommended that she see Psychiatry. She did not do so. However, she states that as Dr. (XX) recommended, she removed herself from conflicts with one particular sibling and this has been very helpful. She thinks she is doing much better in these terms at this point.
OBJECTIVE: The patient is 5 feet 9 inches; weight is 224, up 4 pounds from last year; blood pressure 126/80; pulse 76 and regular. HEENT: Generally benign. She wears glasses. Neck is supple without lymphadenopathy, goiter or bruit appreciated. Lungs: Clear throughout. Heart: Regular rate and rhythm without murmur, rub or gallop appreciated. Breasts are without mass. Axilla negative bilaterally. Abdomen: Soft, nontender. No mass or hepatosplenomegaly appreciated. Pelvic: Exam is deferred. Extremities: Without edema. Pedal pulses are intact bilaterally.
ASSESSMENT AND PLAN:
1. Hyperlipidemia. She is fasting today. We will update level. We gave her a new prescription for her simvastatin.
2. Weight loss: Exercise is strongly advised.
3. Borderline blood pressure: See lifestyle changes above. Update lab work.
4. Issues of stress and anxiety. Again, states she is doing better at this point. She is aware she could seek local provider if she wanted to talk to a therapist or psychiatrist but does not think this is necessary at this point.
5. Left foot issues. She is following with Podiatry as needed.
6. Overweight: We discussed sensible dietary choices, working on an exercise program which fits her schedule and does not bother her foot, etc., and she is hoping to make positive changes in this area.
7. History of squamous cell carcinoma of the nose: She follows with an outside dermatologist and is seeing them within the next couple of weeks. No new lesions of concern.
8. Screening: Mammogram and bone density are current as is tetanus. She is going to schedule eye exam in the near future. Colonoscopy is due this year due to poor prep on previous study, and we will order this. We discussed Zostavax, and we will give her information but we do not have it available at the current time. Tetanus was boosted last year and she will call as needed.
