DATE OF SERVICE: MM/DD/YYYY
CHIEF COMPLAINT: Dry mouth, weight loss, follow up abnormal glucose, and follow up borderline blood pressures.
HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old male, who we have not seen in over a year, who comes in today for evaluation of multiple issues. The patient’s chief concern is dry mouth that has been bothering him off and on for several years, but in the past month, it has become particularly marked and bothersome. The patient saw his dentist about a month ago, who did a thorough mouth examination but could not find any abnormalities. The patient denies any associated dry eyes, difficulty swallowing, or painful swallowing. His other issues are his weight. He lost his sister recently, and he admits that he has not yet come to grips with this. He continues to struggle with the grieving process. He has changed his whole lifestyle around to fill his day with activities such as exercise. He goes running or walking frequently. He has changed his diet to a much healthier diet. He has lost upwards of 20 pounds and actually he feels that he might be too thin. He admits that he feels depressed. He feels lost about his loss, but he has not been open to grief counseling. His sugars have been borderline in the past. Unfortunately, we did not check one last year, as he was not fasting. He saw his urologist in the fall, and his PSA was still nondetectable. Blood pressure has stabilized with the weight loss; although, he attributes that to healthy eating.
PAST MEDICAL HISTORY:
1. H. pylori gastritis and NSAID gastritis, status post treatment.
2. Diverticulosis.
3. History of palpitations with normal echo, preserved ejection fraction.
4. Prostate cancer, status post prostatectomy, has been in remission.
5. Emotional depressive stress reaction from loss of his sister.
6. History of glucose intolerance, mild.
MEDICATIONS: He is only taking nutritional supplements, including coenzyme Q10, L-carnitine, and alpha-lipoic acid.
ALLERGIES: NKDA.
SOCIAL HISTORY: No recreational drug use. He has social alcohol.
FAMILY HISTORY: Negative for colon cancer. Mother had lung cancer, deceased.
PHYSICAL EXAMINATION: Vital Signs: Weight is 120 pounds. His temperature is 97.6. Blood pressure is 120/84. General: This is a pleasant male, sitting up, in no acute respiratory or other distress. HEENT: The sclerae and conjunctivae are unremarkable. The oropharynx is dry without any lesions appreciated. Dentition is intact. External auditory canals are clear. Neck: Supple. No lymphadenopathy. Skin: Warm and moist.
ASSESSMENT AND PLAN:
1. Xerostomia: Unclear etiology. We are going to do blood work today for diabetes screening as well as possibility of Sjogren’s with some antibody levels. He is not interested in seeing the rheumatologist at this time or having a definitive biopsy of his oral mucosa. We will see him back at the end of the month to discuss a trial of something like Salagen.
2. Hypertension: Stable with weight loss.
3. Anorexia: Unclear etiology. We are going to check a thyroid level and some other blood tests.
4. Glucose intolerance: Again, we are going to check an A1c and urinalysis. We will see him back at the end of the month as scheduled, sooner p.r.n.
