[doctor] eugene walker , n- date of birth 4/14/1960 . he's a 61-year-old male who presents today , uh , for a routine follow-up with chronic medical conditions . [doctor] of note , the patient underwent an aortic valve replacement and ascending aortic aneurysm repair on 1/22/2013 . regarding his blood work from 4/10/2021 , the patient's alkaline phosphatate- phosphatase , excuse me , was elevated to 156 . his lipid panel showed elevated total cholesterol of 247 , hdl of 66 , ldl of 166 , and triglycerides at 74 . the patient's tsh was normal at 2.68 . his cbc was unremarkable . his most recent vitamin d level was at the high end of normal at 94 . [doctor] good morning , mr. walker . how are you doing ? i mean , it's been a crazy year . [patient] i'm doing fine , for the most part , but there are a few things i want to cover today . [doctor] sure . go right ahead . [patient] uh , well , i'm having more fatigue , but i do n't know if it's age or if it's just , you know , drained at the end of the day . but i still ride my bike . i ca n't go as fast as i used to . i'm still riding , and , you know , after a long bike ride , i'll sit down and then boom . i'm out , you know ? [doctor] yeah . what's a long bike ride to you ? [patient] uh , 20 to 30 miles . [doctor] 20 to 30 miles on a road bike ? [patient] yeah , road bike . i think it's a time thing . if i had more time , i would try to do my 40 miles , but i have n't done that . obviously , we're too early in the season so my typical ride is , like , 20 , 30 . in years back , i could do 40 on a good day . i can still do 20 but , you know , i'm tired and have to take a break when i get home . [doctor] yeah , i understand . [patient] and tyler's my buddy . he's always nice and waits for me , but i used to be able to beat him . but now , he waits for me all the time . he's older than me and it- it kills me . [doctor] yeah , i can imagine that would upset me too . [patient] well , the last time , you know , you found a heart thing , then . just making sure that the valve is holding out , you know ? [doctor] right . so , when was your last stress test ? [patient] it was september 9th , 2019 , because i'm eight years out from surgery , and back then , they said , you know , it's going to last eight years . and i'm at that year , so i just want to make sure . i asked dr. lewis for an echocardiogram to see how i'm doing . [doctor] yeah . [patient] but it's not ... like , nothing has changed drastically since i saw you . [doctor] okay , good . do you still go down to hopkins at all ? [patient] no , not at all . i just get follow-ups intermittently , here . going there is just ... it's too much stress . [doctor] okay . [patient] one more thing , i want to make sure i do n't forget . my wife and friends tell me that when i walk , i purse my lips when i'm breathing . other doctors have said ,  did you notice your pursed lips breathing ?  i do n't know if that's a bad habit or what . [doctor] okay . is there any wheezing associated with that ? [patient] no , no wheezing . [doctor] and you're able to bike 30 miles and mostly keep up with your friend , tyler , correct ? [patient] yeah . the only other thing i want to mention is it's not like i do routine testicular exams , but i know i have this little nodule on my right testicle . [doctor] on the testicle or the epididymis ? [patient] epididymis . uh , i really do n't know . i'm not super concerned . i read a little online . just wanted to ask you . [doctor] and did you have a vasectomy ? [patient] no . let me pull my notes out and make sure i mentioned everything i wanted to tell you . those were the only things and it's not like my tiredness is depression or anything . i'm a pretty happy guy overall , you know ? i just know you would ask those questions . [doctor] what time are you going to sleep , and about how many hours do you sleep a night ? [patient] um , it varies . usually , i get six to seven hours of sleep . i get out of bed some days to be at work by 7:00 , lecture , and i try to work out in the morning . i- i do n't ... i'm not ... i'm not always successful , and now what i do is i- i do make reservations twice a week for a 5:45 swim in the morning . [doctor] okay , so you're getting six to seven hours of sleep , and has your wife ever mentioned if you snore or stop breathing at any time ? [patient] i believe i snore a little bit , but she's never said anything about me not breathing . [doctor] okay . so , you're currently taking vitamin d3 , around 5000 units on sundays , and two thous ... or 50,000 units on sundays , excuse me , and 2000s on the other six days , and then clindamycin prior to dental procedures , correct ? [patient] yeah , that's right . [doctor] have you had a covid-19 shot yet ? [patient] i've received both . my first dose on january 15th , '21 and my second on february 5th , '21 . [doctor] good . if you'd hop up here on the table , we're just going to do a physical exam . [doctor] well , mr. walker , overall you're doing well . i'm going to order an echocardiogram and a stress test . i also recommend that you follow up with cardiology , i think dr. vincent sanchez would be a great fit for you . [patient] all right . [doctor] also your recent labs showed an elevated alkaline phosphatase level at 156 . now this could be related to your liver but most likely related to your bone health . we're going to check a few labs today . [patient] you're going to have them done today ? [doctor] yes , sir , and we will send the results through your patient portal unless something is way off then we'll give you a call . [patient] sounds good . [doctor] now as far as your breathing , i observed the pursed lip breathing and your exhalation is low . i think you should do a pulmonary function test to further evaluate , and i'll order that as well . [doctor] now the nodule in your right testicle should be evaluated by urology , and we will place that referral today , also . [patient] sounds like i'm going to be busy getting this all checked out . [doctor] yes , sir . now you are due for your mmr and i'm recommend you get the shingles vaccine as well . you have completed your covid-19 , so that's good . [doctor] now i'm going to have , uh ... have you return in about a year for your wellness visit . we'll see you back sooner if needed after i review all those labs and those other studies . [doctor] do you have any other questions for me ? [patient] no , doc . i think you covered it all . [doctor] great . okay , the nurse will , uh , be back in a minute to give you mmr today , and the front desk will line up a time to do the shingles vaccine next month . [patient] thanks , doc . have a great day . [doctor] all right , i used my general physical exam template for respiratory notate : pursed lip breathing , low exhalation phase , clear to oscillation , no wheezing . uh , genitalia notate : right testicle with two to three millimeters palpable nodule does not feel as if it will ... does not feel as if with the epididymis or variococele ; left testicle , normal ; no hernia . all other portions of the physical exam are normal default . [doctor] assessment history of the aortic aneurysm repair : the patient underwent and aortic valve replacement and ascending aortic aneurysm repair on 1/20/2013 . he is doing well overall and currently asymptomatic . he is currently not seen by cardiology routinely . suggest the following up and suggested vincent sanchez as his physician . we will perform an echocardiogram , eh , slash , stress test . [doctor] elevated alkaline phosphatase level . most recent cmd showed elevation at 156 . this could be related to his liver but most likely re- related to his bone health . i've ordered an alkaline phosphatase and again a gt . [doctor] lung field abnormal finding on exona ... excuse me , on examination . the patient has been noted to purse his lips while breathing . he was found himself ... he has found himself feeling more fatigued at the end of the day . he does bicycle around 20 to 30 miles at a time . his exhal- exhalation phase is low on exam , and i've ordered pfts today to further ... for further evaluation . [doctor] the right testicular nodule is about two to three millimeters , i've noted on the exam . there's no hernia palpable , and i have suggested reaching out to ro ... urology for a possible ultrasound . [doctor] preventative health : the most recent blood work was reviewed with no significant abnormalaries ... abnormalities other than the cmv . uh , we will perform mmr titer today . i have suggested the shingles vaccine and he is fully vaccinated against covid-19 . [doctor] patient will return , uh , for a follow-up in one year for a wellness visit , sooner if needed . he is to call with any questions or concerns .
ASSESSMENT

• History of aortic aneurysm repair.
 • Elevated alkaline phosphate level.
 • Lung field abnormal finding on examination.
 • Right testicular nodule.
 • Preventative health.

PLAN

Mr. Eugene Walker is a 61-year-old male who presents today for a routine follow-up of his chronic medical conditions.
 
 History of aortic aneurysm repair.
 - Overall, he is doing well and currently asymptomatic.
 - Currently he is not seen by cardiology routinely and I have suggested he follow up with Dr. Tyler Sanchez.
 - Ordered echocardiogram and stress test.
 
 Elevated alkaline phosphate level.
 - Most recent CMP showed elevation at 156 IU/L.
 - This could be related to his liver but most likely related to his bone health.
 - Ordered an alkaline phosphatase and gamma GT.
 
 Lung field abnormal finding on examination.
 - The patient has been noted to purse his lips while breathing.
 - He had found himself feeling more fatigued at the end of the day.
 - He does cycle 20 to 30 miles at a time.
 - His exhalation phase was low on exam.
 - Ordered pulmonary function testing for further evaluation.
 
 Right testicular nodule.
 - 2 to 3 mm nodule noted on exam. There is no palpable hernia.
 - Referral placed to urology for possible ultrasound.
 
 Preventative health.
 - Most recent blood work reviewed with no significant abnormalities.
 - He is fully vaccinated against COVID-19.
 - Recommend shingles vaccine next month.
 - MMR titer performed today.