CHIEF COMPLAINT: Physical exam.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old male who returns for his annual physical. He states he feels well and reports that he has not yet had his colonoscopy. This had to be rescheduled due to personal reasons.
PAST MEDICAL HISTORY: Hypertension, hyperlipidemia, morbid obesity, mild anemia.
PAST SURGICAL HISTORY: None.
FAMILY MEDICAL HISTORY: Father deceased at age 64 due to some unspecified coronary artery disease. The patient denies any history of diabetes, cancer or cerebrovascular accidents in his family.
SOCIAL HISTORY: The patient is married with 2 adult female children and 2 grandchildren, ages 3 and 1. He notes smoking half pack per day of cigarettes for approximately 10 years, but discontinued 5 years ago. He rarely drinks.
CURRENT MEDICATIONS: Lipitor 10 mg at bedtime, hydrochlorothiazide 12.5 mg, lisinopril 10 mg, vitamins.
ALLERGIES: No known drug allergies.
REVIEW OF SYSTEMS: The patient denies any nausea, vomiting, fevers, chills, dysuria, discharge, weight change, fatigue, night sweats, rashes, weakness, paresthesias, melena, hematochezia, hematemesis, chest pain, shortness of breath, vision changes or change in stool habits. The patient further denies any nocturia.
OBJECTIVE: Vital Signs: Blood pressure 146/86, weight 292-1/2 pounds down 12 pounds from previous physical, height 64-1/2 inches. General: Well-developed, well-nourished, alert, cooperative male, in no apparent distress. HEENT: Pupils equal, round and reactive to light, and extraocular movements intact bilaterally. Oropharynx is nonerythematous and without exudate. Neck: Supple without any lymphadenopathy or thyromegaly. Tympanic membranes show good landmarks bilaterally. Cardiovascular: Regular rate and rhythm. No murmurs, rubs, or gallops. No carotid bruits appreciated upon auscultation. Lungs: Clear to auscultation bilaterally. No wheeze, rales, or rhonchi. Abdomen: Obese, soft, nontender, nondistended with no hepatosplenomegaly appreciated. Normoactive bowel sounds upon auscultation. Extremities: Nonedematous. Neurologic: Cranial nerves II through XII are grossly intact. Deep tendon reflexes +2/4 bilaterally in both upper and lower extremities. Good grip strength noted bilaterally with no involuntary movements. Sensation is intact to pain and light touch. Genitalia: Normal appearing circumcised male genitalia with no discharge, inflammation, or evidence of infection. Testicular exam and inguinal hernia exam within normal limits. Rectal: No masses, polyps or hemorrhoids palpated. Sphincter tone adequate. No blood noted on the exam glove. Hemoccult not performed due to lack of stool in the rectal vault. Prostate was not nodular or tender but was mildly palpably enlarged. Skin: Normal texture and turgor. No rashes, petechiae or suspicious lesions appreciated.
DIAGNOSTIC DATA: PSA, TSH, vitamin D, complete metabolic profile all within normal limits. CBC reveals mild anemia with hemoglobin of 13.2. Lipid profile stable with LDL of 128, HDL of 62 and triglycerides of 55.
ASSESSMENT AND PLAN:
1. Well physical. The patient appears to be doing well. The patient’s blood pressure is slightly elevated at this time. We will increase his lisinopril to 20 mg and have him return in 2-3 weeks for another recheck.
2. Mild anemia. We will recheck his complete blood count and iron profile and remind the patient to rebook his colonoscopy.
3. Health maintenance. The patient is up-to-date on his influenza and tetanus and did have his eye exam this past March.
