SUBJECTIVE: The patient is here for a new patient physical. He has been seen here once before where he received refills on his lorazepam. The patient’s only complaint today is right shoulder pain after injuring it playing four days ago. The patient is requesting the option to take lorazepam twice daily if needed. He says he does not usually need this but would like to have the option of having a second dose available to him. He is aware of the risks of treatment with lorazepam, including dependency and sedation.
PAST MEDICAL HISTORY: Anxiety and sciatica.
PAST SURGICAL HISTORY: None.
SOCIAL HISTORY: The patient is married and has four children. He is a nonsmoker. Drinks alcohol, approximately one drink per day. Recently began an exercise program and is exercising regularly.
FAMILY HISTORY: Father died in his 80s from diabetic complications. Mother died at age 92 of a stroke. Did have one uncle with prostate cancer.
MEDICATIONS: Lorazepam 0.5 mg daily as needed.
REVIEW OF SYSTEMS: Comprehensive 10-point review of systems was conducted and was positive only for anxiety and right shoulder pain.
OBJECTIVE: In general, the patient is obese and in no acute distress. Blood pressure 124/82, pulse 82, respiratory rate 18, weight 226, height 5 feet 7 inches. Head: Normocephalic, atraumatic. Ears: Canals are clear. TMs are normal. Nose: Nares patent. No rhinorrhea. Pharynx: Mucous membranes are moist. No pharyngeal erythema or exudate. Dentition is fair. Eyes: Pupils are equal, round, and reactive to light and accommodation. Extraocular movements are intact without nystagmus. Nonicteric and no discharge. Red reflex present bilaterally. Neck: Supple. No lymphadenopathy. No thyromegaly. Carotid pulses 2+ without bruits. Lungs: Clear to auscultation bilaterally, good air exchange. Heart: Regular rate and rhythm. No murmurs, rubs, or gallops. Abdomen: Soft, nontender, obese. Bowel sounds present in all four quadrants. No palpable organomegaly. Exam limited secondary to body habitus. Musculoskeletal: Right shoulder with tenderness to palpation and palpable muscle spasm over the scapular area. Full range of motion of right shoulder. Otherwise, good muscle bulk and tone, full strength, range of motion bilateral extremities: Neurologic: Grossly nonfocal. Gait and station normal. Patellar reflexes 2+ and equal bilaterally. Skin: No suspicious lesions. GU: Deferred secondary to patient request. Psychiatric: Mood and affect appropriate, not overly depressed or anxious.
ASSESSMENT:
1. Healthy physical exam.
2. Anxiety.
PLAN: We will update labs today, including CBC, CMP, lipid profile, TSH, and PSA. The patient was given stool cards and will return these to us. He will consider colonoscopy, and we will schedule that with us when he is ready. Discussed with the patient screening for colon and prostate cancer. Given the patient is on a low-carb diet, suggested multivitamin and mineral supplement. Discussed weight loss and congratulated the patient on recent weight loss. Encouraged continued exercise. We will contact the patient pending results, and he will follow up with us next year for physical or sooner as needed.
