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CC: Annual Wellness Visit HPI: A 68 year old African American male presents to the clinic today for an annual wellness visit. Previously seen last year, he denies any new issues or significant changes in his health. However, he does admit to some increased feelings of loneliness due to not being able to see his daughter due to the COVID-19 pandemic.  He remains independent in both his ADLs and IADLs. Patient has also expressed concern about staying healthy as he has avoided the gym since the beginning of the pandemic and is hesitant to return with the surge of cases in his area. He continues to monitor his blood pressure with an at home machine. He has has received both doses of the Pfizer COVID vaccination.  ROS:  	General: Denies change in appetite; denies fatigue 	GI: Mild “gassiness” following meals; Denies loose, frequent bowel movements  	Cardiac and Pulmonary: Denies cough or dyspnea  	Male GU: Denies testicular swelling or abnormal discharge  PMH: T2DM (diagnosed 2014); HTN (diagnosed 2017) PSH: Medial meniscus repair (2016) Meds: HCTZ (25 mg po daily for HTN); Metformin (850 mg po daily for T2DM); daily Men’s vitamin;  GasX  prn for “gassiness” Allergies: Penicillin (rash);  No food allergy; No seasonal allergies  SH: Denies previous or current tobacco or recreational drug use. He has an occasional glass of wine on the weekends. He does not drink coffee. Patient tries to eat a well-balanced diet, but still struggles with portion control, especially in the morning following a workout. Due to his avoidance of the gym, he continues to do home workouts, primarily using his newly purchased exercise bike, which he does 20+ miles on daily. Following the passing of his wife in 2016, he lives alone in his townhome. FH: Mother and Father are both deceased; his mother passed d/t T2DM complications, but his father had no chronic issues. His 3 siblings are all living (2 sisters and 1 brother); his brother has hyperlipidemia and one of his sisters has HTN. His daughter is alive and well with no chronic issues.

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Vitals:   BP:  140/90 mm Hg   HR:  86 bpm  Temp:  98.6 F  RR:  16   Weight:  190  lbs   Height:  5’10  BM1:  27.3 General:  Patient is well groomed. Awake, alert, and appears stated age. Pt appears to be in no acute distress.  HEENT: NC/AT, PEERLA, EOMI Cardio: RRR without murmurs, radial and dorsalis pedis pulse +2/4 equal b/l, no pretibial edema Lungs: CTAB; no rales or rhonchi  Abdomen: No scarring or obvious lesions noted; bowel sounds present and equal in all 4 quadrants; percussion tympanic throughout; abdomen is nontender to both superficial and deep palpation MSK: Pt ambulates well without ataxia and sat on exam table w/ no issue. Stands with slight increased kyphosis of the thoracic spine. Neuro: CN 2-12 grossly intact;  b/l  DTR +2/4 at brachioradialis and patella OSE:  T3-5 N RrSl; slight hypertonicity noted of paraspinal muscles

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LABS    CBC: 	Hgb: 16.5 g/dL 	Hematocrit: 50% 	MCV: 93 f/L 	Total WBCs: 9k/dL 	Total Platelets: 400 k/dL BMP: 	Glucose: 97 mg/dL 	BUN: 14 mg/dL 	Creatinine: 1 mg/dL 	Potassium: 4 mmol/L 	Sodium: 136 mmol/L 	Chloride: 100 mmol/L 	Carbon Dioxide: 25 mmol/L TSH: 1.9 IU/L T4: 7.3 ug/dL

Depression Screen (PHQ-9): 5 (mild depression) Cognitive Testing:  28 Vision Testing; 20/20; continues to use bifocals for reading Hearing Testing: No hearing loss noted

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Hypertension  Type II Diabetes Mild indigestion Thoracic somatic dysfunction; T3-5 N  RrSl

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Blood pressure was slightly increased in the office today. He will continue his home monitoring and continue on his current medication HCTZ (25 mg po daily for HTN). Blood pressure will be check again at next visit.  He will also continue with his Metformin and the  GasX  prn.   A low sodium diet as well as portion control has been discussed with the patient  All vaccinations are up to date. Patient has been advised and plans to get his flu shot shortly. Necessary screening protocol was reviewed and is aware he will be due for his next colonoscopy when he turns 70.  Depression questionnaire given in office today noted “mild depression”. Patient’s feelings of increased loneliness were discussed. We have planned for him to get more involved with his family online, though social media which his daughter is able to help him with. The possibility of a therapy referral in the future has been discussed.  Patient consented in the office today to have osteopathic treatment. OMT was performed on the specific spinal segment which he tolerated well.  No changes to his previously completed advanced directive have been made at this time.  Patient will follow up in 1 year for his subsequent annual wellness exam to re-evaluate and note any changes including but not limited to his ADL, blood pressure, and cognitive function.

History