Primary Provider:
CC: Annual PE -fatigue and not sleeping.
History of Present Illness:
Patient presented for HCM exam. Doing OK. Only major concern is that he is not sleeping at nigth. Is a bit stressed over wife with ALZ.
No snoring; is tired during day.
Labs reviewed --not at goal.
No problems with meds.
End of life care reviewed; Healthy lifestyle reviewed. Preventative services reviewed. PSA discussed and he declines; no LUTS.
High risk depression as he assumes caregiver role.
Hypertension History:
He denies headache, chest pain, palpitations, dyspnea with exertion, PND, peripheral edema, and side effects from treatment.
Positive major cardiovascular risk factors include male age 45 years old or older, hyperlipidemia, and hypertension. Negative major cardiovascular risk factors include no history of diabetes, negative family history for ischemic heart disease, and non-tobacco-user status.
Further assessment for target organ damage reveals no history of ASHD, cardiac end-organ damage (CHF/LVH), stroke/TIA, peripheral vascular disease, renal insufficiency, or hypertensive retinopathy.
Lipid Management History:
Positive NCEP/ATP III risk factors include male age 45 years old or older, HDL cholesterol less than 40, and hypertension. Negative NCEP/ATP III risk factors include non-diabetic, no family history for ischemic heart disease, non-tobacco-user status, no ASHD (atherosclerotic heart disease), no prior stroke/TIA, no peripheral vascular disease, and no history of aortic aneurysm.
The patient states that he does not know about the "Therapeutic Lifestyle Change" diet. His compliance with the TLC diet is fair. The patient does not know about adjunctive measures for cholesterol lowering.
Past Medical History:
Reviewed history from 09/21/2012 and no changes required:
HTN
Colon CA
-- s/p recection 2001
-- Last Colonoscopy 2009
Renal Cell CA
-- s/p recestion 1998
RLL Lung Carcinoid
-- s/p resection 6/02
Normal Cardiac Catheterization, 2007
Basal Cell CA, nose, resected
Past Surgical History:
Reviewed history from 04/16/2007 and no changes required:
R Hemicolectomy
Lung Resection
Kidney Resection
Basal Cell CA resection
Family History:
Reviewed history and no changes required:
Mom -- Died age 94
Dad -- Died age 92
Social History:
Reviewed history from 06/14/2011 and no changes required:
Married; lives in
Caregiver for wife with ALZ
Risk Factors:
Tobacco use: former smoker
Year quit: 2000
Family History Risk Factors:
Family History of MI in females < 65 years old: no
Family History of MI in males < 55 years old: no
Review of Systems
General
Complains of weakness and sleep disorder.
Denies fever and weight loss.
Eyes
Denies vision loss - both eyes.
ENT
Denies difficulty swallowing.
CV
Denies chest pain or discomfort, racing/skipping heart beats, shortness of breath with exertion, palpitations, and swelling of hands or feet.
Resp
Denies shortness of breath.
GI
Denies abdominal pain, change in bowel habits, and bloody stools.
GU
See HPI
Complains of nocturia and erectile dysfunction.
Denies urinary frequency and urinary hesitancy.
MS
Complains of joint pain and back pain.
Denies muscle weakness.
Derm
a bunch of fleshy lesions; not concerning to him
Neuro
Denies numbness and tingling.
Psych
Denies anxiety and depression.
Endo
Complains of weight change.
Heme
Denies bleeding and abnormal bruising.
Vital Signs:
Patient Profile:
Height: 67.0 inches
Weight: 247.5 pounds
BMI: 38.90
BSA: 2.22
Temp: 96.6 degrees F temporal
Pulse rate: 80 / minute
Pulse rhythm: regular
BP sitting: 142 / 78 (left arm)
Cuff size: large
Vitals Entered By:
Physical Exam
General:
Obese male, no acute distress
Eyes:
PERRL/EOM intact, conjunctiva and sclera clear with out nystagmus.
Ears:
TM's intact and clear with normal canals with grossly normal hearing.
Nose:
no deformity, discharge, inflammation, or lesions.
Mouth:
no deformity or lesions with good dentition.
Neck:
no masses, thyromegaly, or abnormal cervical nodes.
Lungs:
clear bilaterally to auscultation.
Heart:
non-displaced PMI, chest non-tender; regular rate and rhythm, S1, S2 without murmurs, rubs, or gallops
Abdomen:
normal bowel sounds; no hepatosplenomegaly no ventral,umbilical hernias or masses noted.
Prostate:
normal size prostate without nodules or asymmetry
Skin:
Benign nevi diffusely
AK on Ear and Forehead
Psych:
alert and cooperative; normal mood and affect; normal attention span and concentration.
Test Management:
Tests Reviewed:
BUN: 16 04/25/2014
Creatinine: 1.08 04/25/2014
Sodium: 136 04/25/2014
Potassium: 3.9 04/25/2014
Chloride: 102 04/25/2014
SGOT (AST): 20 04/25/2014
SGPT (ALT): 27 04/25/2014
PROTEIN, TOT: 7.5 09/15/2012
ALBUMIN: 3.2 09/15/2012
ALK PHOS: 75 09/15/2012
BILI TOTAL: 1.00 09/15/2012
CHOLESTEROL: 173 04/25/2014
LDL:
NOT DONE MG/DL (04/25/2014)
HDL: 32 04/25/2014
Impression & Recommendations:
Problem # 1: INSOMNIA (ICD-780.52)
Remeron.
Problem # 2: IMPAIRED FASTING GLUCOSE (ICD-790.21)
Educated.
Problem # 3: DYSLIPIDEMIA (ICD-272.9)
Will try to reduce carbs and follow; recheck in August. Flag made.
His updated medication list for this problem includes:
Zocor 40 Mg Tabs (Simvastatin) ..... 1 po q pm
Problem # 4: HYPERTENSION (ICD-401.9)
A bit up. Increase exercise and watch
His updated medication list for this problem includes:
Micardis Hct 80-12.5 Mg Tabs (Telmisartan-hctz) ..... 1 tab po q.d.
Problem # 5: Hx of ADENOCARCINOMA, COLON (ICD-153.9)
Due for scope. Refer.
Orders:
Colonoscopy (COLONOS)
Problem # 6: Preventive Health Care (ICD-V70.0)
See below and discussion above.
Problem # 7: ACTINIC KERATOSIS (ICD-702.0)
5 Lesions frozen
Orders:
Destruction 1st Lesion (CPT-17000)
Destruction 2-14 Lesions (CPT-17003)
Problem # 8: ERECTILE DYSFUNCTION (ICD-302.72)
His updated medication list for this problem includes:
Viagra 100 Mg Tab (Sildenafil citrate) ..... 1/2 - 1 tab po prn
Medications Added to Medication List This Visit:
1) Viagra 100 Mg Tab (Sildenafil citrate) .... 1/2 - 1 tab po prn
2) Remeron 15 Mg Tab (Mirtazapine) .... 1 po qhs
Hypertension Assessment/Plan:
The patient's hypertensive risk group is category B: At least one risk factor (excluding diabetes) with no target organ damage. Today's blood pressure is 142/78.
Lipid Assessment/Plan:
Based on NCEP/ATP III, the patient's risk factor category is "2 or more risk factors and a calculated 10 year CAD risk of > 20%". The patient's lipid goals have been set as follows: Total cholesterol goal is 200; LDL cholesterol goal is 100; HDL cholesterol goal is 40; Triglyceride goal is 150. His cholesterol goal has not been met. His HDL goal has not been met. His Triglyceride goal has not been met.
His BMI is calculated to be 38.90. The patient has triglyceride level over 150, an HDL less than 40 (male), and systolic blood pressure greater than 130. This meets the criteria for dysmetabolic syndrome. Recommended treatments for the dysmetabolic syndrome were discussed with the patient including weight management, regular exercise, better blood pressure control, and lipid management.
Colorectal Screening:
Colon Cancer risk factors:
PMH of Colorectal CA
Current Recommendations:
Colonoscopy recommended: scheduled
PSA Screening:
Reviewed PSA screening recommendations: Pro's and Cons's of PSA discussed and patient chooses to defer
Immunization & Chemoprophylaxis:
Tetanus vaccine: Tdap (06/17/2011)
Influenza vaccine: Historical (09/13/2013)
Pneumovax: Pneumovax (06/17/2011)
Patient Instructions:
1) Try Remeron for sleep
2) Try Viagra as needed
3) More exercise, less carbs -- "mediterranean diet" or "low carb" diets (South Beach, the "Zone")
4) Recheck cholesterol in August -- if not better need to adjust meds
5) Can schedule to have skin lesions removed
6) Skin lesion frozen today
7) Colonoscopy!
Prescriptions:
VIAGRA 100 MG TAB (SILDENAFIL CITRATE) 1/2 - 1 tab PO prn #9 x 6
REMERON 15 MG TAB (MIRTAZAPINE) 1 po qhs #30 x 0
Need Office Visit CPT codes Reviewed
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