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Annual Physical Exam Medical Transcription Sample Report

REASON FOR VISIT:  Annual physical exam and followup of several medical problems.

HISTORY OF PRESENT ILLNESS:  The patient is a (XX)-year-old Hispanic male who presented to the office for annual physical exam.  He has hyperlipidemia.  Unfortunately, he is intolerant to Lipitor and Zocor, which causes joint aches.  Currently, he is not on any medications.  He had repeat fasting lipids checked, which showed that his cholesterol is still significantly high.  The patient does watch his diet and also has some exercise.  The patient also has a family history of breast cancer.  His sister has breast cancer.  Last year, his mother also was diagnosed with breast cancer.  The patient has not noticed any breast lump.  At this visit, the patient has several other complaints. He feels general fatigue more significant in the morning.  No fever.  No night sweating.  Appetite has been fine.  No diarrhea or abdominal pain.  Also, notes constipation.  He would like to check it out.  Another complaint is right thumb pain for the past 3 months.  He did not notice any swelling, and he would like it checked out.

REVIEW OF SYSTEMS:  Please see interview questionnaire.

PAST MEDICAL HISTORY:  Hyperlipidemia, eczema of left knee, right hip degenerative joint disease, external hemorrhoids, anxiety, seborrheic keratosis, melanocytic nevi, left cervical radiculopathy, and MRI of the C-spine consistent with degenerative disk disease.

SOCIAL HISTORY:  The patient is divorced.  Smoker and admits to having alcoholic beverages.

FAMILY HISTORY:  Significant for father and brother with skin cancer, grandmother with CAD, grandfather with diabetes, grandfather with colon cancer, and sister and mother with breast cancer.  Otherwise, no family history of prostate cancer or ovarian cancer.  No family history of hypertension.



PHYSICAL EXAMINATION:  Vital Signs:  Temperature 98.6, pulse 66, and blood pressure 164/74.  Height 5 feet 8 inches and weight 160 pounds.  General:  The patient is a Hispanic male, in no acute distress.  HEENT:  Unremarkable.  Neck:  Supple.  No JVD.  No thyromegaly.  No lymphadenopathy.  Heart:  Regular rhythm and rate.  No murmur, gallop, or rub.  Lungs:  Clear to auscultation bilaterally.  Breasts:  Bilateral breasts with no palpable mass.  No nipple discharge.  No skin retraction.  No axillary lymphadenopathy.  Back:  No spinal tenderness.  No CVA tenderness.  Abdomen:  Soft, nontender, and nondistended.  No hepatosplenomegaly.  Bowel sounds are present.  Genitourinary:  Unremarkable.  Rectal:  Normal sphincter tone.  No pedal mass.  Stool guaiac negative.  Extremities:  No clubbing, cyanosis, or edema.  Left side of face, there is  tenderness to palpation.  Full range of motion of the joints.  No joint fluid is detected.  No erythema.

LABORATORY DATA:  Normal CBC.  Normal BUN and creatinine.  Normal fasting blood sugar.  AST and ALT also within normal limits.  Fasting lipids, triglycerides 100, total cholesterol 214, HDL 64, and LDL 202.  UA also was within normal limits.

EKG last year showed normal sinus rhythm.  No acute ischemic changes.

ASSESSMENT AND PLAN:  This is a (XX)-year-old Hispanic male in good health.  However, the patient has hypercholesterolemia, not improved with diet control and exercise.  We discussed management and also discussed trying another statin. He agrees.  We gave him a prescription for Lescol 20 mg, instructed the patient to take every other day.  If he has no side effects noticed, he can increase to 20 mg daily.  We booked the patient for liver function at 2 months.  We will repeat his fasting lipid and liver function in 6 months.  Regarding his right thumb, most likely it is tendinitis.  No evidence to suggest a fracture.  The patient may take NSAID p.r.n. for symptom control.  He will let us know if his symptom does not improve by NSAIDs.

Regarding the patient’s strong family history of breast cancer, we discussed management and recommended gene screen for the family members.  We will continue annual breast exam.  The patient is instructed to call if he notices any breast lump.  Regarding his family history of colon cancer, at this visit, he has negative stool guaiac.  We will continue annual rectal exam.  We will go ahead and obtain colonoscopy for colon cancer screen.

Regarding his general fatigue, unclear etiology.  We will check his TSH to rule out any possible steroid dysfunction.  We will encourage the patient to abstain from smoking, limit alcohol intake.  Also encouraged he avoid sun overexposure, use sunscreen at least 30 SPF.  The patient will follow up p.r.n.

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