Full Name: A.G.

Date of Birth: XX/XX/1976

Age: 45

Date and Time: 11/16/2021 9:30 AM

Location: Amazing Medical Services, Jamaica, NY

Source of Information: Self

Reliability: Reliable patient 

Mode of Transport: Private Vehicle

Chief Complaint: Annual exam    

History of Present Illness: 

45 y/o M, with no past medical history, who comes in today for annual visit. Patient has no complaints currently. Patient denies fever, chills, chest pain, shortness of breath, abdominal pain, nausea, vomiting, change in bowel habits, dysuria, penile discharge, headache or dizziness. Patient states he has not received the COVID vaccine for personal reasons. He denies having a colonoscopy in the past.

Past Medical History:

• Denies

Past Surgical History:

• Hand surgery 1998, unknown type of surgery, no complications

Past Hospitalizations:

• Denies hospitalizations

Family History:

• Father – alive,             HLD
• Mother – alive, HTN
• Sister – alive and well

Medications:

• Denies taking any medications

Vaccinations:

• Declined COVID-19 and influenza vaccines

Allergies:

• Shellfish – vomiting
• No known drug or seasonal allergies

Social history:

• Employed as a maintenance worker.
• Lives with long-time girlfriend. Reports to only one female sexual partner, denies using barrier protection.
• Patient admits to occasional alcohol use, approximately one to two beers per week. Denies tobacco use or illicit drug use.
• Nutrition: Reports to eating out most meals, as he is out all day for work. Eats a breakfast sandwich in the morning on most days, a deli sandwich for lunch, and dinner varies. Denies eating a diet rich in fruits and vegetables.
• Sleep: Reports to sleeping 6-8 hours per night.

Review of Systems: 

General: Denies fever, chills, night sweats, fatigue, weakness, weight loss/gain or decreased appetite. 

Skin, hair, nails: Denies changes in texture, excessive dryness or sweating, discolorations, pruritis or changes in hair distribution.

Head: Denies headache, dizziness, or head trauma. 

Eyes: Denies blurry vision, double vision, or loss of vision. 

Ears: Denies hearing loss, discharge, tinnitus, ear pain. 

Nose/Sinuses: Denies nasal congestion, nasal discharge, sinus pressure/pain, or loss of smell.

Mouth/throat: Denies sore throat, bleeding gums, mouth ulcers. 

Neck: Denies localized swelling/lumps or stiffness/decreased range of motion.

Respiratory: Denies cough, shortness of breath, wheezing, sputum production. 

Cardiovascular: Denies chest pain, palpitations, leg edema, hypertension, syncope or known heart murmur. 

GI: Denies abdominal pain, nausea, vomiting, hematemesis, diarrhea, or constipation. 

GU: Denies heavy vaginal bleeding, dysuria, hesitancy, flank pain, frequency, hematuria, or urgency. 

MSK: Denies any muscle or joint pain, redness, or stiffness. 

Neuro: Denies weakness, dizziness, lightheadedness, headaches, sensory disturbances. 

Physical Exam: 

VS: T 98.7 F, BP 115/73, HR 66 bpm, RR 14, O2 sat 98%, Ht5’10.5”, Wt 216 lb, BMI 30.61

Gen: Alert and oriented, in no acute distress. Well-nourished and well-appearing with good hygiene. Sitting comfortably in chair.

Skin: Warm and moist, no rash. No ecchymosis.

Head: Normocephalic, atraumatic 

Eyes: PERRLA. Sclera non-icteric. EOMI. No nystagmus. Conjunctiva pink, no discharge.  

Ears: Pinna, tragus and external ear nontender. No lesions or swelling of bilateral ear canals. Normal tympanic membranes

Nose: Nasal septum midline.

Throat: Uvula midline. No erythema or exudates. No tonsillar enlargement.

Neck: Supple. No thyroid enlargement, no lymphadenopathy.

Cardiovascular: Regular rate and rhythm. S1 and S2 with no murmurs. 

Pulmonary: No respiratory distress. Clear to auscultation bilaterally. Non-labored breathing.

Abdomen: Soft, nontender, nondistended.

Extremities: No edema. 2+ DP/PT pulses bilaterally.

MSK: Full range of motion of all extremities. 

Neurological: CN II-XII grossly intact. Gross sensation intact.

Psychiatric: Appropriate mood and affect.

Assessment: 

45 y/o M with no PMHx, who presents for annual exam with no complaints.

Plan: 

• Annual labs: CBC, CMP, lipid profile, PSA, urinalysis, and HIV testing
• Patient referred to gastroenterologist for colon cancer screening
• Patient agreed with plan and all questions were answered.

Addendum:

Patient’s labs

CBC

WBC: 4.1

RBC: 4.73

Hgb: 13.3 

HCT: 41.3 

MCV: 87.3

MCH: 28.1

MCHC: 32.2

RDW: 11.9

PLT: 195

CMP

Glucose: 103

BUN: 14

Creatinine: 1.12

eGFR nonAA: 79

eGFR AA: 91 

Sodium: 138

Potassium: 4.1

Chloride: 102

CO2: 28 

Calcium: 9.1 

Protein total: 7.1

Albumin: 4.3

Globulin: 2.8 

Albumin/globulin ratio: 1.5 

Bilirubin total: 0.4 

Alk phos: 77

AST: 24

ALT:  22 

Lipid profile:

Triglycerides: 114

Cholesterol, total: 244

HDL: 60

LDL: 161

Chol/HDLC ratio: 4.1

Non-HDL cholesterol: 184

UA:

Color: yellow

Appearance: clear

Bilirubin, ketones, occult blood, bacteria, hyaline cast, protein, nitrite and glucose all negative

Gravity: 1.023

pH: 6.0

Leukocyte esterase: 1+

WBC: 10-20

RBC: 0-2

Squamous cell epithelial: 0-5

HIV AG/AB, 4th generation: non-reactive 

PSA:

PSA free: 0.3 

PSA, total: 1.0 

PSA, % free: 30 

Plan:

11/18/2021: Called patient to discuss lab results. Discussed abnormal UA, lipid profile and mildly elevated glucose at 103. Patient did not eat prior to bloodwork. Lifestyle modification discussed. Patient should be exercising at least 30 minutes a day for five days a week. Dietary counseling also provided. Discussed that the patient should decrease “junk” food, fried foods, and food high in sugar. Emailed patient a handout from the American Heart Association regarding high cholesterol and what foods are appropriate to eat. Will continue lifestyle modification for three to four months and repeat lipid profile. Patient will follow up in office in two weeks for repeat urinalysis with culture reflex, gonorrhea and chlamydia testing and will also obtain hemoglobin A1c. Patient verbalized understanding and agreed with plan.