Male AWV Note - Cannon

Chief Complaint: - Annual wellness visit HPI: 1. Hypertension: Patient reports a history of hypertension for the past 5 years. Currently managed with medication, but reports occasional headaches. No recent changes in medication or lifestyle. 2. Hyperlipidemia: Diagnosed 3 years ago, currently on statins. Reports no side effects from medication. Male AWV - Nutrition: Patient follows a balanced diet, including fruits, vegetables, and lean proteins. - Exercise: Engages in moderate exercise, such as walking, for 30 minutes, 5 times a week. - Falls: No recent falls reported. - EtOH/Tobacco: Consumes alcohol socially, approximately 2-3 drinks per week. Non-smoker. - HTN screen: Blood pressure today is 130/85 mmHg. - Cholesterol: Most recent LDL level is 120 mg/dL. - 10 year CV risk %: 15%. - STD screen: No STD screening requested today. - One time HIV/HBV/HCV screen: Screened for HIV, HBV, and HCV last year, all results negative. - Skin cancer screening: No concerning lesions noted. - Depression (PHQ2/9): PHQ9 score of 3, indicating minimal depression. - Anxiety (GAD2/7): GAD7 score of 2, indicating minimal anxiety. - Med review: Medication list reviewed and confirmed. - PSA discussion: PSA testing discussed, patient opted to defer. - DEXA if at high risk: Not discussed. - Colon CA screen: Screening colonoscopy discussed, patient agrees to schedule. - AAA screen: Not discussed. - Lung CA Screen: Not discussed. - Advance Care Planning: Advance directive discussed, patient has a living will. Medical Diagnoses: 1. Hypertension 2. Hyperlipidemia Specialist Care: 1. Dr. Sarah Lee, Cardiologist Medications: 1. Lisinopril 10 mg daily 2. Atorvastatin 20 mg daily Review of Systems Constitutional: No fever, chills, fatigue, or weight changes. Eyes: No vision changes, redness, pain, or discharge. Ears, Nose, Throat: No hearing loss, tinnitus, nasal congestion, rhinorrhea, sore throat, or dysphagia. Cardiovascular: No chest pain, palpitations, or edema. Respiratory: No shortness of breath, cough, or wheezing. Gastrointestinal: No nausea, vomiting, diarrhea, constipation, or abdominal pain. Genitourinary: No dysuria, hematuria, urinary frequency, or urgency. Musculoskeletal: No joint pain, stiffness, or swelling. Skin: No rashes, lesions, or itching. Neurologic: No headaches, dizziness, numbness, or weakness. Psychiatric: No anxiety, depression, or mood changes. Endocrine: No polyuria, polydipsia, or heat/cold intolerance. Hematologic/Lymphatic: No easy bruising, bleeding, or lymphadenopathy. Allergic/Immunologic: No allergies, sneezing, or hives. Physical Exam Constitutional: Well-nourished, well-developed male in no acute distress. Vital Signs: Blood pressure 130/85 mmHg, heart rate 72 bpm, respiratory rate 16 breaths/min, temperature 36.8°C. Cardiovascular: Regular rate and rhythm, no murmurs, rubs, or gallops. Respiratory: Clear to auscultation bilaterally, no wheezes, rales, or rhonchi. Labs / Imaging / Diagnostic Tests: 1. Lipid panel from 6 months ago: LDL 120 mg/dL, HDL 50 mg/dL, Triglycerides 150 mg/dL. Assessment & Plan 1. Preventive Care Assessment: Patient is due for a colonoscopy as part of routine cancer screening. Plan: - Schedule colonoscopy. - Continue current exercise and diet regimen. - Follow up in 1 year for next annual wellness visit. 2. Hypertension (I10) Assessment: Blood pressure is well-controlled on current medication. Plan: - Continue Lisinopril 10 mg daily. - Monitor blood pressure at home. - Follow up in 6 months for blood pressure check. 3. Hyperlipidemia (E78.5) Assessment: Lipid levels are stable on current statin therapy. Plan: - Continue Atorvastatin 20 mg daily. - Repeat lipid panel in 1 year. Procedure Note: Patient Name: John Doe Date of Procedure: 1 November 2024 Procedure Performed: None Indication: N/A Pre-Procedure Diagnosis: N/A Post-Procedure Diagnosis: N/A Details of Procedure: Consent: N/A Preparation: N/A Procedure Steps: N/A Findings: N/A Complications: None. Post-Procedure Care: Patient tolerated the procedure well. Post-procedure monitoring: N/A Follow-up plan: N/A Medications Administered: None.