Male Health Maintenance

HISTORY:

Presents for a wellness visit

Current symptoms: ‍ ‍noneno changes in health



Medications:

‍ ‍none

Adherence: ‍goodaveragepoor, ‍adverse effects

Over-the-counter supplements: ‍ ‍none, ‍vitamin D, ‍calcium



Past medical history: ‍ ‍unremarkable



Family history: ‍unremarkable, ‍CAD, ‍stroke, ‍diabetes, ‍colon cancer, ‍prostate cancer



Social history:

Smoking: ‍neversmokerformer smoker, ‍ pack-years

Alcohol: ‍nonesociallyexcessive, ‍ drinks per ‍dayweek

Recreational drugs: ‍none ‍cannabis, ‍IVDU

Diet: ‍goodaveragepoor, ‍high in salt, ‍high in carbs, ‍high in fat, ‍vegan

Physical activity: ‍adequateaveragesedentary

Weight: ‍ ‍lbskg, ‍gainunchangedloss

Occupation: ‍



Labs:

Creatinine: ‍ ‍normal

Na: ‍ ‍normal, K: ‍ ‍normal

Hb: ‍ ‍normal

HbA1c: ‍ ‍normal

Lipids: ‍normal, Cholesterol: ‍, LDL: ‍, HDL: ‍, Triglycerides: ‍

TSH: ‍ ‍normal

PSA: ‍ ‍normal

Urinalysis: ‍ ‍normalproteins



EXAM:

General appearance: ‍well-appearing

Vital signs: ‍normal, BP ‍, HR ‍, RR ‍, SpO2 ‍ %, Temp ‍°

Measurements: weight: ‍ kg, height: ‍ cm, waist: ‍ cm, BMI: ‍

Eyes: -R: ‍normal, -L: ‍normal, ‍

Ears: -R: ‍normal, -L: ‍normal

Nose: ‍normal

Throat: ‍normalrednessexudate

Neck: ‍normallymphadenopathy

Heart: ‍RRR, ‍normal S1 and S2

Lungs: ‍clearabnormal sounds, ‍retractions

Abdomen: ‍softsemi-softtense, ‍non-tender ‍, ‍non-distended, ‍

Anorectal: DRE ‍normal, prostate ‍normal, anus ‍normal



Genital: ‍normal, testicles ‍normal, penis ‍normal

Skin: ‍no rash

Extremities: ‍edema, ‍warm, cap refill ‍< 3 sec> 3 sec, pulses ‍normal, ‍

Musculoskeletal: joints ‍ ‍normal, ‍no limited ROM

Neurologic: cranial nerves ‍normal, strength ‍5/5 throughout, sensation ‍normal, reflexes ‍2+ throughout, cerebellar function ‍normal, gait ‍stable

Mental status: ‍alert, ‍oriented, speech ‍clear, mood ‍normal, thought process ‍organized, ‍no suicidal ideation, judgment ‍good



ASSESSMENT:

‍Good health overall



PLAN:

- Colonoscopy

- FIT test

- Blood work: ‍CBC, ‍lytes, ‍creatinine, ‍LFTs, ‍albumin, ‍TSH, ‍lipid profile, ‍fasting glucose, ‍HbA1c, ‍PSA

- Dietary counseling: balanced diet rich in fruits, vegetables, lean proteins, and whole grains

- Exercise counseling: at least 150 minutes of moderate-intensity or 75 minutes of high-intensity aerobic activity per week, plus muscle-strengthening activities twice per week

- Weight management counseling

- Smoking cessation counseling

- Alcohol moderation counseling

- Vaccinations: annual ‍influenza, ‍pneumococcal if aged ≥ 65 or conditions, ‍shingles if aged 50 and older, ‍tetanus/diphtheria every 10 years, ‍HPV

- Medication renewal for ‍61224 months

- Follow-up in ‍ ‍monthsyears

- Return if new symptoms develop or condition worse